吸气努力对伴有自主呼吸活动的机械通气患者液体反应性预测中脉压变异准确性的影响：一项前瞻性队列研究。
Inspiratory effort impacts the accuracy of pulse pressure variations for fluid responsiveness prediction in mechanically ventilated patients with spontaneous breathing activity: a prospective cohort study.
作者信息
Chen Hui, Liang Meihao, He Yuanchao, Teboul Jean-Louis, Sun Qin, Xie Jianfen, Yang Yi, Qiu Haibo, Liu Ling
机构信息
Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, People's Republic of China.
Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Soochow University, No. 899 Pinghai Road, Suzhou, 215000, People's Republic of China.
出版信息
Ann Intensive Care. 2023 Aug 17;13(1):72. doi: 10.1186/s13613-023-01167-0.
BACKGROUND
Pulse pressure variation (PPV) is unreliable in predicting fluid responsiveness (FR) in patients receiving mechanical ventilation with spontaneous breathing activity. Whether PPV can be valuable for predicting FR in patients with low inspiratory effort is unknown. We aimed to investigate whether PPV can be valuable in patients with low inspiratory effort.
METHODS
This prospective study was conducted in an intensive care unit at a university hospital and included acute circulatory failure patients receiving volume-controlled ventilation with spontaneous breathing activity. Hemodynamic measurements were collected before and after a fluid challenge. The degree of inspiratory effort was assessed using airway occlusion pressure (P) and airway pressure swing during a whole breath occlusion (ΔP) before fluid challenge. Patients were classified as fluid responders if their cardiac output increased by ≥ 10%. Areas under receiver operating characteristic (AUROC) curves and gray zone approach were used to assess the predictive performance of PPV.
RESULTS
Among the 189 included patients, 53 (28.0%) were defined as responders. A PPV > 9.5% enabled to predict FR with an AUROC of 0.79 (0.67-0.83) in the whole population. The predictive performance of PPV differed significantly in groups stratified by the median value of P (P < 1.5 cmHO and P ≥ 1.5 cmHO), but not in groups stratified by the median value of ΔP (ΔP < - 9.8 cmHO and ΔP ≥ - 9.8 cmHO). Specifically, in patients with P < 1.5 cmHO, PPV was associated with an AUROC of 0.90 (0.82-0.99) compared with 0.68 (0.57-0.79) otherwise (p = 0.0016). The cut-off values of PPV were 10.5% and 9.5%, respectively. Besides, patients with P < 1.5 cmHO had a narrow gray zone (10.5-11.5%) compared to patients with P ≥ 1.5 cmHO (8.5-16.5%).
CONCLUSIONS
PPV is reliable in predicting FR in patients who received controlled ventilation with low spontaneous effort, defined as P < 1.5 cmHO. Trial registration NCT04802668. Registered 6 February 2021, https://clinicaltrials.gov/ct2/show/record/NCT04802668.
背景
在接受机械通气且有自主呼吸活动的患者中，脉压变异（PPV）在预测液体反应性（FR）方面并不可靠。PPV在吸气努力较低的患者中能否用于预测FR尚不清楚。我们旨在研究PPV在吸气努力较低的患者中是否有价值。
方法
这项前瞻性研究在一家大学医院的重症监护病房进行，纳入了接受容量控制通气且有自主呼吸活动的急性循环衰竭患者。在液体冲击前后收集血流动力学测量值。在液体冲击前，使用气道阻断压（P）和全呼气阻断期间的气道压力摆动（ΔP）评估吸气努力程度。如果心输出量增加≥10%，则将患者分类为液体反应者。使用受试者工作特征（AUROC）曲线下面积和灰色区域法评估PPV的预测性能。
结果
在纳入的189例患者中，53例（28.0%）被定义为反应者。PPV>9.5%能够在总体人群中以AUROC为0.79（0.67 - 0.83）预测FR。按P的中位数分层的组中PPV的预测性能有显著差异（P<1.5 cmH₂O和P≥1.5 cmH₂O），但按ΔP的中位数分层的组中无显著差异（ΔP< - 9.8 cmH₂O和ΔP≥ - 9.8 cmH₂O）。具体而言，在P<1.5 cmH₂O的患者中，PPV的AUROC为0.90（0.82 - 0.99），而在其他情况下为0.68（0.57 - 0.79）（p = 0.0016）。PPV的截断值分别为10.5%和9.5%。此外，与P≥1.5 cmH₂O的患者（8.5 - 16.5%）相比，P<1.5 cmH₂O的患者灰色区域较窄（10.5 - 11.5%）。
结论
PPV在预测接受低自主努力控制通气（定义为P<1.5 cmH₂O）的患者的FR方面是可靠的。试验注册号NCT04802668。于2021年2月6日注册，https://clinicaltrials.gov/ct2/show/record/NCT04802668。
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