Jiang Lianlian, Chen Hui, Chang Wei, Sun Qin, Yuan Xueyan, Wu Zongsheng, Xie Jianfeng, Liu Ling, Yang Yi
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.
Ann Intensive Care. 2025 Jan 13;15(1):6. doi: 10.1186/s13613-025-01427-1.
The association between bedside ventilatory parameters-specifically arterial carbon dioxide pressure (PaCO) and ventilatory ratio (VR)-and mortality in patients with acute respiratory distress syndrome (ARDS) remains a topic of debate. Additionally, the persistence of this association over time is unclear. This study aims to investigate the relationship between 28-day mortality in ARDS patients and their longitudinal exposure to ventilatory inefficiency, as reflected by serial measurements of PaCO and VR.
We conducted a secondary analysis of four randomized controlled trials (FACTT, ALTA, EDEN, and SAILS) from the ARDS Network. All included patients were intubated and received mechanical ventilation. Patients were excluded if they underwent extracorporeal life support or were on mechanical ventilation for less than one day. The primary outcome was 28-day mortality. Bayesian joint models were employed to estimate the strength of associations over time.
A total of 2,851 patients were included in our analysis. The overall 28-day mortality rate was 21.3%, with a median duration of invasive mechanical ventilation of 9 days (IQR: 4-28 days). After adjustment, each daily increment in PaCO (HR 1.008, 95% CI 0.997-1.018) was not associated with mortality, while a daily increment in VR (HR 1.548, 95% CI 1.309-1.835) was associated with increased mortality. This association persisted during the prolonged stages (Days 0-23) of mechanical ventilation. Furthermore, a significant increase in the risk of death was related to daily exposure to VR > 2 (HR 1.088 per day, 95% CI 1.034-1.147) and its cumulative effect (HR 1.085 per area, 95% CI 1.050-1.122), whereas PaCO was found to be insignificant.
VR, which reflects ventilatory inefficiency, should be closely monitored during invasive mechanical ventilation. Cumulative exposure to high intensities of VR may be associated with increased mortality in patients with ARDS.
床边通气参数，特别是动脉二氧化碳分压（PaCO）和通气比（VR）与急性呼吸窘迫综合征（ARDS）患者死亡率之间的关联仍是一个有争议的话题。此外，这种关联随时间的持续性尚不清楚。本研究旨在调查ARDS患者28天死亡率与其长期通气效率低下之间的关系，通气效率低下通过连续测量PaCO和VR来反映。
我们对ARDS网络的四项随机对照试验（FACTT、ALTA、EDEN和SAILS）进行了二次分析。所有纳入患者均已插管并接受机械通气。如果患者接受体外生命支持或机械通气时间少于一天，则将其排除。主要结局是28天死亡率。采用贝叶斯联合模型估计随时间变化的关联强度。
我们的分析共纳入2851例患者。总体28天死亡率为21.3%，有创机械通气的中位持续时间为9天（四分位间距：4 - 28天）。调整后，PaCO每天增加（风险比1.008，95%置信区间0.997 - 1.018）与死亡率无关，而VR每天增加（风险比1.548，95%置信区间1.309 - 1.835）与死亡率增加有关。这种关联在机械通气的延长阶段（第0 - 23天）持续存在。此外，死亡风险显著增加与每天暴露于VR > 2有关（每天风险比1.088，95%置信区间1.034 - 1.147）及其累积效应（每单位面积风险比1.085，95%置信区间1.050 - 1.122），而发现PaCO无显著意义。
反映通气效率低下的VR在有创机械通气期间应密切监测。ARDS患者累积暴露于高强度VR可能与死亡率增加有关。
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