Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
Centre for Medical Sciences-CISMed, University of Trento, Trento, Italy.
Crit Care. 2024 Oct 24;28(1):343. doi: 10.1186/s13054-024-05143-3.
Sub-phenotyping of acute respiratory distress syndrome (ARDS) could be useful for evaluating the severity of ARDS or predicting its responsiveness to given therapeutic strategies, but no studies have yet investigated the heterogeneity of patients with severe ARDS requiring veno-venous extracorporeal membrane oxygenation (V-V ECMO).
We conducted this retrospective multicenter observational study in adult patients with severe ARDS treated by V-V ECMO. We performed latent class analysis (LCA) for identifying sub-phenotypes of severe ARDS based on the radiological and clinical findings at the start of ECMO support. Multivariate Cox regression analysis was conducted to investigate the differences in mortality and association between the PEEP setting of ≥ 10 cmHO and mortality by the sub-phenotypes.
We identified three sub-phenotypes from analysis of the data of a total of 544 patients with severe ARDS treated by V-V ECMO, as follows: Dry type (n = 185; 34%); Wet type (n = 169; 31%); and Fibrotic type (n = 190; 35%). The 90-days in-hospital mortality risk was higher in the patients with the Fibrotic type than in those with the Dry type (adjusted hazard ratio [95% confidence interval] 1.75 [1.10-2.79], p = 0.019) or the Wet type (1.50 [1.02-2.23], p = 0.042). The PEEP setting of ≥ 10 cmHO during the first 3 days of ECMO decreased the 90-days in-hospital mortality risk only in patients with the Wet type, and not in those with the Dry or Fibrotic type. A significant interaction effect was observed between the Wet type and the PEEP setting of ≥ 10 cmHO in relation to the 90-day in-hospital mortality (p = 0.036).
The three sub-phenotypes showed different mortality rates and different relationships between higher PEEP settings in the early phase of V-V ECMO and patient outcomes. Our data suggest that we may need to change our management approach to patients with severe ARDS during V-V ECMO according to their clinical sub-phenotype.
急性呼吸窘迫综合征（ARDS）的亚表型分型可能有助于评估 ARDS 的严重程度或预测其对特定治疗策略的反应性，但尚无研究探讨需要静脉-静脉体外膜肺氧合（V-V ECMO）治疗的严重 ARDS 患者的异质性。
我们对接受 V-V ECMO 治疗的成人严重 ARDS 患者进行了这项回顾性多中心观察性研究。我们基于 ECMO 支持开始时的影像学和临床发现，进行潜在类别分析（LCA）以确定严重 ARDS 的亚表型。采用多变量 Cox 回归分析探讨死亡率的差异以及亚表型与 PEEP 设置为≥10 cmH2O 与死亡率之间的关联。
我们从总共 544 例接受 V-V ECMO 治疗的严重 ARDS 患者的数据中分析出 3 种亚表型，如下：干燥型（n=185；34%）；湿润型（n=169；31%）；和纤维化型（n=190；35%）。纤维化型患者的 90 天院内死亡率风险高于干燥型（校正风险比[95%置信区间] 1.75[1.10-2.79]，p=0.019）或湿润型（1.50[1.02-2.23]，p=0.042）。ECMO 开始后前 3 天的 PEEP 设置为≥10 cmH2O 仅降低了湿润型患者的 90 天院内死亡率风险，而对干燥型或纤维化型患者没有影响。湿型和 PEEP 设置为≥10 cmH2O 与 90 天院内死亡率之间存在显著的交互效应（p=0.036）。
这 3 种亚表型显示出不同的死亡率和 V-V ECMO 早期较高 PEEP 设置与患者结局之间的不同关系。我们的数据表明，根据患者的临床亚表型，我们可能需要改变严重 ARDS 患者接受 V-V ECMO 期间的治疗方法。
