比较机械通气治疗成人急性呼吸衰竭时采用限定性压力通气和小潮气量通气策略的随机对照试验。

Comparison of limited driving pressure ventilation and low tidal volume strategies in adults with acute respiratory failure on mechanical ventilation: a randomized controlled trial.

机构信息

Faculty of Medicine, Siriraj Hospital, Mahidol University, 2, Prannok Road, Bangkok Noi, Bangkok 10700, Thailand.

Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.

出版信息

Ther Adv Respir Dis. 2024 Jan-Dec;18:17534666241249152. doi: 10.1177/17534666241249152.

DOI:10.1177/17534666241249152

PMID:38726850

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC11088295/

Abstract

BACKGROUND

Ventilator-induced lung injury (VILI) presents a grave risk to acute respiratory failure patients undergoing mechanical ventilation. Low tidal volume (LTV) ventilation has been advocated as a protective strategy against VILI. However, the effectiveness of limited driving pressure (plateau pressure minus positive end-expiratory pressure) remains unclear.

OBJECTIVES

This study evaluated the efficacy of LTV against limited driving pressure in preventing VILI in adults with respiratory failure.

DESIGN

A single-centre, prospective, open-labelled, randomized controlled trial.

METHODS

This study was executed in medical intensive care units at Siriraj Hospital, Mahidol University, Bangkok, Thailand. We enrolled acute respiratory failure patients undergoing intubation and mechanical ventilation. They were randomized in a 1:1 allocation to limited driving pressure (LDP; ⩽15 cmHO) or LTV (⩽8 mL/kg of predicted body weight). The primary outcome was the acute lung injury (ALI) score 7 days post-enrolment.

RESULTS

From July 2019 to December 2020, 126 patients participated, with 63 each in the LDP and LTV groups. The cohorts had the mean (standard deviation) ages of 60.5 (17.6) and 60.9 (17.9) years, respectively, and they exhibited comparable baseline characteristics. The primary reasons for intubation were acute hypoxic respiratory failure (LDP 49.2%, LTV 63.5%) and shock-related respiratory failure (LDP 39.7%, LTV 30.2%). No significant difference emerged in the primary outcome: the median (interquartile range) ALI scores for LDP and LTV were 1.75 (1.00-2.67) and 1.75 (1.25-2.25), respectively ( = 0.713). Twenty-eight-day mortality rates were comparable: LDP 34.9% (22/63), LTV 31.7% (20/63), relative risk (RR) 1.08, 95% confidence interval (CI) 0.74-1.57, = 0.705. Incidences of newly developed acute respiratory distress syndrome also aligned: LDP 14.3% (9/63), LTV 20.6% (13/63), RR 0.81, 95% CI 0.55-1.22, = 0.348.

CONCLUSIONS

In adults with acute respiratory failure, the efficacy of LDP and LTV in averting lung injury 7 days post-mechanical ventilation was indistinguishable.

CLINICAL TRIAL REGISTRATION

The study was registered with the ClinicalTrials.gov database (identification number NCT04035915).

摘要

背景

呼吸机相关性肺损伤（VILI）是机械通气治疗的急性呼吸衰竭患者面临的严重风险。小潮气量（LTV）通气被认为是预防 VILI 的一种保护策略。然而，限制驱动压（平台压减去呼气末正压）的效果仍不清楚。

目的

本研究评估 LTV 与限制驱动压在预防成人呼吸衰竭患者 VILI 中的效果。

设计

单中心、前瞻性、开放标签、随机对照试验。

方法

本研究在泰国曼谷玛希隆大学 Siriraj 医院的重症监护病房进行。我们纳入了接受插管和机械通气的急性呼吸衰竭患者。他们按照 1:1 分配到限制驱动压（LDP；≤15cmH2O）或 LTV（≤8ml/kg 预测体重）组。主要结局是入组后 7 天的急性肺损伤（ALI）评分。

结果

2019 年 7 月至 2020 年 12 月，共有 126 名患者参与，LDP 组和 LTV 组各 63 名。两组的平均（标准差）年龄分别为 60.5（17.6）岁和 60.9（17.9）岁，且基线特征相当。插管的主要原因是急性低氧性呼吸衰竭（LDP 组 49.2%，LTV 组 63.5%）和与休克相关的呼吸衰竭（LDP 组 39.7%，LTV 组 30.2%）。主要结局无显著差异：LDP 和 LTV 组的中位（四分位间距）ALI 评分分别为 1.75（1.00-2.67）和 1.75（1.25-2.25）（ = 0.713）。28 天死亡率也相似：LDP 组 34.9%（22/63），LTV 组 31.7%（20/63），相对风险（RR）1.08，95%置信区间（CI）0.74-1.57， = 0.705。新发急性呼吸窘迫综合征的发生率也一致：LDP 组 14.3%（9/63），LTV 组 20.6%（13/63），RR 0.81，95%CI 0.55-1.22， = 0.348。