叹息对急性低氧性呼吸衰竭患者死亡率的异质性影响：来自PROTECTION研究的见解。

Heterogeneous impact of Sighs on mortality in patients with acute hypoxemic respiratory failure: insights from the PROTECTION study.

作者信息

Rezoagli Emanuele, Fornari Carla, Fumagalli Roberto, Grasselli Giacomo, Volta Carlo Alberto, Navalesi Paolo, Knafelj Rihard, Brochard Laurent, Pesenti Antonio, Mauri Tommaso, Foti Giuseppe

机构信息

School of Medicine and Surgery, University of Milano-Bicocca, 20900, Monza, Italy.

Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.

出版信息

Ann Intensive Care. 2024 Oct 5;14(1):153. doi: 10.1186/s13613-024-01385-0.

DOI:10.1186/s13613-024-01385-0

PMID:39368033

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC11456003/

Abstract

BACKGROUND

Sigh breaths may impact outcomes in acute hypoxemic respiratory failure (AHRF) during assisted mechanical ventilation. We investigated whether sigh breaths may impact mortality in predefined subgroups of patients enrolled in the PROTECTION multicenter clinical trial according to: 1.the physiological response in oxygenation to Sigh (responders versus non-responders) and 2.the set levels of positive end-expiratory pressure (PEEP) (High vs. Low-PEEP). If mortality differed between Sigh and No Sigh, we explored physiological daily differences at 7-days.

RESULTS

Patients were randomized to pressure support ventilation (PSV) with Sigh (Sigh group) versus PSV with no sigh (No Sigh group). (1) Sighs were not associated with differences in 28-day mortality in responders to baseline sigh-test. Contrarily-in non-responders-56 patients were randomized to Sigh (55%) and 28-day mortality was lower with sighs (17%vs.36%, log-rank p = 0.031). (2) In patients with PEEP > 8cmHO no difference in mortality was observed with sighs. With Low-PEEP, 54 patients were randomized to Sigh (48%). Mortality at 28-day was reduced in patients randomised to sighs (13%vs.31%, log-rank p = 0.021). These findings were robust to multivariable adjustments. Tidal volume, respiratory rate and ventilatory ratio decreased with Sigh as compared with No Sigh at 7-days. Ventilatory ratio was associated with mortality and successful extubation in both non-responders and Low-PEEP.

CONCLUSIONS

Addition of Sigh to PSV could reduce mortality in AHRF non-responder to Sigh and exposed to Low-PEEP. Results in non-responders were not expected. Findings in the low PEEP group may indicate that insufficient PEEP was used or that Low PEEP may be used with Sigh. Sigh may reduce mortality by decreasing physiologic dead space and ventilation intensity and/or optimizing ventilation/perfusion mismatch.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; Identifier: NCT03201263.

摘要

背景

在辅助机械通气期间，叹息呼吸可能会影响急性低氧性呼吸衰竭（AHRF）的预后。我们根据以下因素调查了叹息呼吸是否会影响参与PROTECTION多中心临床试验的患者预定义亚组的死亡率：1. 氧合对叹息的生理反应（反应者与无反应者）；2. 呼气末正压（PEEP）的设定水平（高PEEP与低PEEP）。如果叹息组和无叹息组之间的死亡率存在差异，我们探讨了第7天时的生理日常差异。

结果

患者被随机分为接受带叹息的压力支持通气（PSV）（叹息组）和接受无叹息的PSV（无叹息组）。（1）对于基线叹息试验的反应者，叹息与28天死亡率的差异无关。相反，在无反应者中，56例患者被随机分配到叹息组（55%），叹息组的28天死亡率较低（17%对36%，对数秩检验p=0.031）。（2）在PEEP>8cmH₂O的患者中，叹息对死亡率没有影响。在低PEEP组中，54例患者被随机分配到叹息组（48%）。随机分配到叹息组的患者28天死亡率降低（13%对31%，对数秩检验p=0.021）。这些发现经多变量调整后依然可靠。与无叹息组相比，第7天时叹息组的潮气量、呼吸频率和通气比降低。通气比与无反应者和低PEEP组的死亡率及成功拔管相关。