急性呼吸窘迫综合征患者在静脉-静脉体外膜肺氧合期间早期重新采用俯卧位：一项前瞻性观察研究和倾向匹配分析

Early reapplication of prone position during venovenous ECMO for acute respiratory distress syndrome: a prospective observational study and propensity-matched analysis.

作者信息

Wang Rui, Tang Xiao, Li Xuyan, Li Ying, Liu Yalan, Li Ting, Zhao Yu, Wang Li, Li Haichao, Li Meng, Li Hu, Tong Zhaohui, Sun Bing

机构信息

Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China.

出版信息

Ann Intensive Care. 2024 Aug 20;14(1):127. doi: 10.1186/s13613-024-01365-4.

DOI:10.1186/s13613-024-01365-4

PMID:39162882

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC11336129/

Abstract

BACKGROUND

A combination of prone positioning (PP) and venovenous extracorporeal membrane oxygenation (VV-ECMO) is safe, feasible, and associated with potentially improved survival for severe acute respiratory distress syndrome (ARDS). However, whether ARDS patients, especially non-COVID-19 patients, placed in PP before VV-ECMO should continue PP after a VV-ECMO connection is unknown. This study aimed to test the hypothesis that early use of PP during VV-ECMO could increase the proportion of patients successfully weaned from ECMO support in severe ARDS patients who received PP before ECMO.

METHODS

In this prospective observational study, patients with severe ARDS who were treated with VV-ECMO were divided into two groups: the prone group and the supine group, based on whether early PP was combined with VV-ECMO. The proportion of patients successfully weaned from VV-ECMO and 60-day mortality were analyzed before and after propensity score matching.

RESULTS

A total of 165 patients were enrolled, 50 in the prone and 115 in the supine group. Thirty-two (64%) and 61 (53%) patients were successfully weaned from ECMO in the prone and the supine groups, respectively. The proportion of patients successfully weaned from VV-ECMO in the prone group tended to be higher, albeit not statistically significant. During PP, there was a significant increase in partial pressure of arterial oxygen (PaO) without a change in ventilator or ECMO settings. Tidal impedance shifted significantly to the dorsal region, and lung ultrasound scores significantly decreased in the anterior and posterior regions. Forty-five propensity score-matched patients were included in each group. In this matched sample, the prone group had a higher proportion of patients successfully weaned from VV-ECMO (64.4% vs. 42.2%; P = 0.035) and lower 60-day mortality (37.8% vs. 60.0%; P = 0.035).

CONCLUSIONS

Patients with severe ARDS placed in PP before VV-ECMO should continue PP after VV-ECMO support. This approach could increase the probability of successful weaning from VV-ECMO.

TRIAL REGISTRATION

ClinicalTrials.Gov: NCT04139733. Registered 23 October 2019.

摘要

背景

俯卧位通气（PP）与静脉-静脉体外膜肺氧合（VV-ECMO）联合应用对于重症急性呼吸窘迫综合征（ARDS）是安全、可行的，且可能提高生存率。然而，ARDS患者，尤其是非新型冠状病毒肺炎（COVID-19）患者，在VV-ECMO前采用PP，在连接VV-ECMO后是否应继续采用PP尚不清楚。本研究旨在验证以下假设：在接受VV-ECMO治疗的重症ARDS患者中，在VV-ECMO期间早期使用PP可提高成功撤机的患者比例，这些患者在ECMO前已接受PP。

方法

在这项前瞻性观察性研究中，接受VV-ECMO治疗的重症ARDS患者根据是否早期联合PP分为两组：俯卧位组和仰卧位组。在倾向评分匹配前后，分析成功撤机的患者比例和60天死亡率。

结果

共纳入165例患者，俯卧位组50例，仰卧位组115例。俯卧位组和仰卧位组分别有32例（64%）和61例（53%）患者成功撤机。俯卧位组成功撤机的患者比例有更高的趋势，尽管无统计学意义。在PP期间，动脉血氧分压（PaO）显著升高，而呼吸机或ECMO设置无变化。潮气量阻抗显著向背部区域转移，肺超声评分在前后区域显著降低。每组纳入45例倾向评分匹配的患者。在这个匹配样本中，俯卧位组成功撤机的患者比例更高（64.4%对42.2%；P = 0.035），60天死亡率更低（37.8%对60.0%；P = 0.035）。