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较低与较高的呼气末正压相比对ICU非ARDS患者无呼吸机天数的影响
作者:小柯机器人 发布时间:2020/12/14 15:15:29

荷兰阿姆斯特丹大学医学中心Marcus J. Schultz团队比较了较低与较高的呼气末正压相比对ICU非ARDS患者无呼吸机天数的影响。2020年12月9日,该研究发表在《美国医学会杂志》上。

对于没有急性呼吸窘迫综合征(ARDS)的危重病人,有创通气是否可以使用较低的呼气末正压(PEEP)尚不确定。

为了确定在28天的机械通气持续时间方面,采用较低的PEEP策略是否不劣于较高的PEEP策略,2017年10月26日至2019年12月17日,研究组在荷兰的8个重症监护病房(ICU)中进行了一项非劣效性随机临床试验。

研究组共招募了980名无ARDS的患者,预计不会在24小时内拔管,随机分配接受有创通气,其中476例使用较低的PEEP(0-5 cm H2O),493例使用较高的PEEP(8 cm H2O)。主要结局为第28天的无呼吸机天数。

在980名患者中,共有969名(99%)完成了试验,中位年龄为66岁,女性占36%。在第28天,较低PEEP组患者中位无呼吸机天数为18天,较高PEEP组患者为17天,平均比率为1.04。

较低PEEP组和较高PEEP组中严重低氧血症的发生率分别为20.6%与17.6%,风险比为1.17; 需要实施抢救的比率分别为19.7%和14.6%,风险比为1.35。较低PEEP组和较高PEEP组患者的28天死亡率分别为38.4%和42.0%,风险比为0.89。其他次要结局无统计学差异。

研究结果表明,对于没有ARDS、预计在24小时之内不会拔管的ICU患者,就第28天无呼吸机天数而言,较低的PEEP策略并不逊于较高的PEEP策略。

附:英文原文

Title: Effect of a Lower vs Higher Positive End-Expiratory Pressure Strategy on Ventilator-Free Days in ICU Patients Without ARDS: A Randomized Clinical Trial

Author: Writing Committee and Steering Committee for the RELAx Collaborative Group, Anna Geke Algera, Luigi Pisani, Ary Serpa Neto, Sylvia S. den Boer, Frank F. H. Bosch, Karina Bruin, Pauline M. Klooster, Nardo J. M. Van der Meer, Ralph O. Nowitzky, Ilse M. Purmer, Mathilde Slabbekoorn, Peter E. Spronk, Jan van Vliet, Jan J. Weenink, Marcelo Gama de Abreu, Paolo Pelosi, Marcus J. Schultz, Frederique Paulus

Issue&Volume: 2020-12-09

Abstract:

Importance  It is uncertain whether invasive ventilation can use lower positive end-expiratory pressure (PEEP) in critically ill patients without acute respiratory distress syndrome (ARDS).

Objective  To determine whether a lower PEEP strategy is noninferior to a higher PEEP strategy regarding duration of mechanical ventilation at 28 days.

Design, Setting, and Participants  Noninferiority randomized clinical trial conducted from October 26, 2017, through December 17, 2019, in 8 intensive care units (ICUs) in the Netherlands among 980 patients without ARDS expected not to be extubated within 24 hours after start of ventilation. Final follow-up was conducted in March 2020.

Interventions  Participants were randomized to receive invasive ventilation using either lower PEEP, consisting of the lowest PEEP level between 0 and 5 cm H2O (n=476), or higher PEEP, consisting of a PEEP level of 8 cm H2O (n=493).

Main Outcomes and Measures  The primary outcome was the number of ventilator-free days at day 28, with a noninferiority margin for the difference in ventilator-free days at day 28 of 10%. Secondary outcomes included ICU and hospital lengths of stay; ICU, hospital, and 28- and 90-day mortality; development of ARDS, pneumonia, pneumothorax, severe atelectasis, severe hypoxemia, or need for rescue therapies for hypoxemia; and days with use of vasopressors or sedation.

Results  Among 980 patients who were randomized, 969 (99%) completed the trial (median age, 66 [interquartile range {IQR}, 56-74] years; 246 [36%] women). At day 28, 476 patients in the lower PEEP group had a median of 18 ventilator-free days (IQR, 0-27 days) and 493 patients in the higher PEEP group had a median of 17 ventilator-free days (IQR, 0-27 days) (mean ratio, 1.04; 95% CI, 0.95-∞; P=.007 for noninferiority), and the lower boundary of the 95% CI was within the noninferiority margin. Occurrence of severe hypoxemia was 20.6% vs 17.6% (risk ratio, 1.17; 95% CI, 0.90-1.51; P=.99) and need for rescue strategy was 19.7% vs 14.6% (risk ratio, 1.35; 95% CI, 1.02-1.79; adjusted P=.54) in patients in the lower and higher PEEP groups, respectively. Mortality at 28 days was 38.4% vs 42.0% (hazard ratio, 0.89; 95% CI, 0.73-1.09; P=.99) in patients in the lower and higher PEEP groups, respectively. There were no statistically significant differences in other secondary outcomes.

Conclusions and Relevance  Among patients in the ICU without ARDS who were expected not to be extubated within 24 hours, a lower PEEP strategy was noninferior to a higher PEEP strategy with regard to the number of ventilator-free days at day 28. These findings support the use of lower PEEP in patients without ARDS.

DOI: 10.1001/jama.2020.23517

Source: https://jamanetwork.com/journals/jama/fullarticle/2774078

期刊信息

JAMA-Journal of The American Medical Association:《美国医学会杂志》,创刊于1883年。隶属于美国医学协会,最新IF:51.273
官方网址:https://jamanetwork.com/
投稿链接:http://manuscripts.jama.com/cgi-bin/main.plex