Prevalence and prognosis of cor pulmonale during protective ventilation for acute respiratory distress syndrome
Prevalence and prognosis of cor pulmonale during protective ventilation for acute respiratory distress syndrome
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DOI：
10.1007/s00134-013-2941-9
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发表时间：
2013-10-01
影响因子：
38.9
通讯作者：
Dessap, Armand Mekontso
中科院分区：
文献类型：
--
作者：
Boissier, Florence;Katsahian, Sandrine;Dessap, Armand Mekontso
肺血管功能障碍在急性呼吸窘迫综合征（ARDS）中很常见，但关于保护性通气治疗ARDS期间肺心病的患病率和预后存在争议。连续226例中重度ARDS（柏林定义）患者，在确诊ARDS后的前3天内接受经食管超声心动图（TEE）检查，通气平台压限制在30 cmH（2）O（平均PEEP为8.8 +/-A3.6 cmH（2）O）。肺心病定义为右心室扩张伴室间隔运动障碍，49例患者检出肺心病（患病率为22%，95%可信区间为16- 27%）。多因素Logistic回归分析发现，肺损伤的感染性原因和较高的驾驶压力是肺心病的独立相关因素。肺心病患者在TEE时表现出更高的休克发生率（需要血管活性药物），并且在ARDS过程中更常采用俯卧位和/或一氧化氮作为严重低氧血症的连续治疗。肺心病组的28天死亡率明显高于对照组（60%比36%，P < 0.01）。多因素Logistic回归分析显示McCabe和杰克逊分级、与肺炎无关的肺损伤、吸入性或脓毒症、乳酸酸中毒、驾驶压和肺心病是28天死亡率的独立危险因素。肺心病与脓毒症和较高的驱动压力值有关，是我们研究中28天死亡率的独立危险因素。
Pulmonary vascular dysfunction is common during acute respiratory distress syndrome (ARDS), but there is controversy concerning prevalence and prognosis of cor pulmonale during protective ventilation for ARDS.This was a prospective observational study in an academic medical intensive care unit in France. Two hundred and twenty-six consecutive patients with moderate to severe ARDS (Berlin definition) ventilated with plateau pressure limited at 30 cmH(2)O (mean PEEP of 8.8 +/- A 3.6 cmH(2)O) underwent transesophageal echocardiography (TEE) within the first 3 days after the diagnosis of ARDS. Cor pulmonale was defined as a dilated right ventricle associated with septal dyskinesia.Cor pulmonale was detected in 49 patients (prevalence of 22 %; 95 % confidence interval, 16-27 %). Multivariate logistic regression identified infectious causes of lung injury and higher driving pressures as independent factors associated with cor pulmonale. Patients with cor pulmonale exhibited a higher incidence of shock (need for vasoactive drug) at the time of TEE and were more often managed with prone positioning and/or nitric oxide as adjunctive therapy for severe hypoxemia during ARDS course. The 28-day mortality rate was significantly higher in the group with cor pulmonale (60 vs. 36 %, p < 0.01). Multivariate logistic regression identified McCabe and Jackson class, lung injury not related to pneumonia, aspiration, or sepsis, lactic acidosis, driving pressure, and cor pulmonale as independent risk factors for 28-day mortality.Cor pulmonale occurrence is not negligible in ARDS patients ventilated with airway pressure limitation. Cor pulmonale was associated with sepsis and higher values of driving pressure and was an independent risk factor for 28-day mortality in our series.