Abel S J, Finney S J, Brett S J, Keogh B F, Morgan C J, Evans T W
Unit of Critical Care, Imperial College School of Medicine, Royal Brompton Hospital, London, UK.
Thorax. 1998 Apr;53(4):292-4. doi: 10.1136/thx.53.4.292.
A study was undertaken to investigate possible reductions in mortality and/or changes in outcome predictive factors in patients with the acute respiratory distress syndrome (ARDS) managed in a single centre.
The study was a prospective observational cohort study of two patient populations with ARDS. Group 1 comprised 41 patients enrolled between May 1990 and April 1993, and group 2 consisted of 78 patients enrolled between June 1993 and March 1997. The end points of the study were mortality and various factors predictive of death.
There was a marked reduction in mortality between groups 1 and 2 (66% versus 34%; relative risk 1.77; CI 1.23 to 2.55). There were no significant differences between the groups in terms of age (40.6 (3.3) versus 45.5 (2.2) years), APACHE score (14.5 (0.72) versus 13.6 (0.1)), lung injury score (2.95 (0.07) versus 2.8 (0.1)), incidence of multi-organ failure (29% versus 32%), incidence of sepsis (31% versus 39%), or PaO2/FIO2 (kPa) ratio (11.8 (0.67) versus 12.0 (0.6)). There was a significantly lower proportion of men in group 1 (51% versus 74%). The case mix of the two groups was closely matched: following elective surgery 48% versus 48%, trauma 17% versus 16%, primary lung injury 12% versus 24%. Patients in group 1 were supported using several ventilatory and other modes (volume preset, non-inverse ratio ventilation, n = 15; pressure controlled inverse ratio ventilation (PC-IRV), n = 11; ultra high frequency jet ventilation (UHFJV), n = 13; an intravascular oxygenation device (IVOX) and extracorporeal gas exchange (ECGE), n = 2). Within group 1 no significant difference in mortality was observed between the patients on volume controlled ventilation and the remainder. In group 2 all patients received PC-IRV (n = 78) but, in addition, some received other support techniques (UHFJV n = 4, ECGE n = 2). In group 1 only sepsis on admission (21% (survivors) versus 56% (non-survivors)) predicted death. In group 2 age of survivors and non-survivors (41.2 (2.6) versus 52.6 (3.5)), APACHE score (12.2 (0.6) versus 15.8 (0.9)), and PaO2/FIO2 (12.8 (0.86) versus 10.5 (0.72)) predicted survival, but not the incidence of sepsis or multi-organ failure.
In recent years a highly significant reduction in mortality associated with ARDS has been observed between two groups of patients well matched for disease severity and case mix. Changes in ICU organisation rather than specific interventions may account for this reduction, although different ventilatory and other management strategies used in the two groups may also be relevant.
开展了一项研究，以调查在单一中心接受治疗的急性呼吸窘迫综合征（ARDS）患者的死亡率可能降低的情况和/或结局预测因素的变化。
该研究是对两组ARDS患者进行的前瞻性观察队列研究。第1组包括1990年5月至1993年4月入组的41例患者，第2组由1993年6月至1997年3月入组的78例患者组成。研究的终点是死亡率和各种死亡预测因素。
第1组和第2组之间的死亡率有显著降低（66%对34%；相对风险1.77；可信区间1.23至2.55）。两组在年龄（40.6（3.3）岁对45.5（2.2）岁）、急性生理与慢性健康状况评分系统（APACHE）评分（14.5（0.72）对13.6（0.1））、肺损伤评分（2.95（0.07）对2.8（0.1））、多器官功能衰竭发生率（29%对32%）、脓毒症发生率（31%对39%）或动脉血氧分压/吸入氧分数（PaO2/FIO2）（kPa）比值（11.8（0.67）对12.0（0.6））方面无显著差异。第1组男性比例显著较低（51%对74%）。两组的病例组合紧密匹配：择期手术后分别为48%对48%，创伤后分别为17%对16%，原发性肺损伤后分别为12%对24%。第1组患者采用多种通气和其他模式进行支持（容量预设、非反比通气，n = 15；压力控制反比通气（PC - IRV），n = 11；超高频喷射通气（UHFJV），n = 13；血管内氧合装置（IVOX）和体外气体交换（ECGE），n = 2）。在第1组中，容量控制通气患者与其余患者之间未观察到死亡率有显著差异。在第2组中，所有患者均接受PC - IRV（n = 78），但此外，一些患者还接受了其他支持技术（UHFJV n = 4，ECGE n = 2）。在第1组中，仅入院时的脓毒症（21%（幸存者）对56%（非幸存者））可预测死亡。在第2组中，幸存者和非幸存者的年龄（41.2（2.6）对52.6（3.5））、APACHE评分（12.2（0.6）对15.8（0.9））和PaO2/FIO2（12.8（0.86）对10.5（0.72））可预测生存，但脓毒症或多器官功能衰竭的发生率不能预测。
近年来，在两组疾病严重程度和病例组合匹配良好的患者中，观察到与ARDS相关的死亡率显著降低。尽管两组使用的不同通气和其他管理策略可能也有影响，但重症监护病房（ICU）组织方式的改变而非特定干预措施可能是导致这种降低的原因。
