Squara P, Dhainaut J F, Artigas A, Carlet J
Réanimation Polyvalente, Hôpital Victor Dupouy, Argenteuil, France.
Intensive Care Med. 1998 Oct;24(10):1018-28. doi: 10.1007/s001340050710.
Although the acute respiratory distress syndrome (ARDS) was identified as long as 30 years ago, potential therapeutic objectives have been defined from small series rather than large trials. Moreover, relationships between ARDS and hemodynamics are unclear. The European Collaborative ARDS Study was designed to identify factors influencing the pathogenesis, severity, and prognosis of ARDS. Analysis of the hemodynamic profiles collected during this study and of their contribution to the above-mentioned facets of ARDS is the focus of the present report.
Prospective clinical study.
38 European intensive care units (ICUs).
We collected 2758 sets of data from 586 patients, including baseline data, data on proven or suspected causes of ARDS differentiating direct and nondirect lung injury, and data on baseline status including multiple organ dysfunction (MOD) with differentiation of primary ARDS from ARDS secondary to severe systemic disorders. Events during follow-up were also recorded, including whether the acute respiratory failure did or did not improve after 24 h (groups A and B, respectively). When available, hemodynamic data were recorded at enrollment (day 0), on days 1-3, 7, 14, and 21, and at discharge or at the time of death in the ICU.
Although the rate of pre-existing disease and the nature and rate of complications varied widely among etiologic categories, differences in the hemodynamic profile occurred only between primary and secondary ARDS. Both at inclusion and during the course of the illness, variables that were used to investigate Va/Q mismatch [arterial oxygen tension (PaO2, arterial oxygen saturation, right-to-left shunt, and the PaO2/fractional inspired oxygen (FIO2) ratio] predicted survival. High pulmonary artery pressure (PAP) and low systemic artery pressure (SAP) were also related to the prognosis. In the logistic regression model including hemodynamic and oxygen-related variables, however, the only independent predictors of survival were the ratio of right over left ventricular stroke work (RVSW/LVSW) and the PaO2/FIO2 ratio at admission. On day 2, the best prognostic model included: age [odds ratio (OR) = 1.04, p = 0.0004], opportunistic pneumonia as the cause of ARDS (OR = 3.2, p = 0.03), existence of MOD (OR = 1.9, p = 0.03), PaO2/FIO2 (OR = 0.96, p = 0.005), and RVSW/LVSW (OR = 25, p = 0.02). A high RVSW/LVSW ratio, high systolic PAP, low diastolic SAP, and low PaO2/FIO2, and increased right atrial pressure were negative prognostic indicators during follow-up.
In addition to the cause of ARDS and the early time-course of lung function, a high systolic PAP and a low diastolic SAP were strong independent indicators of survival.
尽管急性呼吸窘迫综合征（ARDS）早在30年前就已被确认，但潜在的治疗目标是根据小规模研究系列而非大型试验确定的。此外，ARDS与血流动力学之间的关系尚不清楚。欧洲协作性ARDS研究旨在确定影响ARDS发病机制、严重程度和预后的因素。本报告重点分析了该研究期间收集的血流动力学数据及其对ARDS上述各方面的影响。
前瞻性临床研究。
38个欧洲重症监护病房（ICU）。
我们收集了来自586例患者的2758组数据，包括基线数据、区分直接和非直接肺损伤的ARDS确诊或疑似病因数据，以及包括多器官功能障碍（MOD）的数据，区分原发性ARDS与继发于严重全身性疾病的ARDS。还记录了随访期间的事件，包括急性呼吸衰竭在24小时后是否改善（分别为A组和B组）。如有血流动力学数据，在入组时（第0天）、第1 - 3天、第7天、第14天和第21天以及出院时或在ICU死亡时记录。
尽管不同病因类别中既往疾病发生率、并发症的性质和发生率差异很大，但血流动力学特征仅在原发性和继发性ARDS之间存在差异。在纳入时和疾病过程中，用于研究通气/血流比值失调的变量[动脉血氧分压（PaO2）、动脉血氧饱和度、右向左分流以及PaO2/吸入氧分数（FIO2）比值]可预测生存。高肺动脉压（PAP）和低体动脉压（SAP）也与预后相关。然而，在包含血流动力学和氧相关变量的逻辑回归模型中，生存的唯一独立预测因素是右心室与左心室每搏功比值（RVSW/LVSW）和入院时的PaO2/FIO2比值。在第2天，最佳预后模型包括：年龄[比值比（OR） = 1.04，p = 0.0004]、机会性肺炎作为ARDS病因（OR = 3.2，p = 0.03）、存在MOD（OR = 1.9，p = 0.03）、PaO2/FIO2（OR = 0.96，p = 0.005）以及RVSW/LVSW（OR = 25，p = 0.02）。高RVSW/LVSW比值、高收缩期PAP、低舒张期SAP、低PaO2/FIO2以及右心房压力升高是随访期间的不良预后指标。
除了ARDS的病因和肺功能的早期病程外，高收缩期PAP和低舒张期SAP是生存的强有力独立指标。
