Mechanical ventilation guided by esophageal pressure in acute lung injury.
Mechanical ventilation guided by esophageal pressure in acute lung injury.
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DOI：
10.1056/nejmoa0708638
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发表时间：
2008-11-13
期刊：
影响因子：
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通讯作者：
Loring SH
中科院分区：
文献类型：
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作者：
Talmor D;Sarge T;Malhotra A;O'Donnell CR;Ritz R;Lisbon A;Novack V;Loring SH
小潮气量通气和呼气末正压通气（PEEP）可提高急性肺损伤或急性呼吸窘迫综合征（ARDS）患者的生存率；然而，正压的最佳水平一直难以确定。在这项初步研究中，我们通过使用食管球囊导管来估计肺压。我们认为，尽管胸膜压测量的准确性受到技术限制，但使用胸膜压测量将使我们能够找到一个可以维持氧合的PEEP值，同时防止因反复肺泡塌陷或过度扩张引起的肺损伤。我们随机分配急性肺损伤或ARDS患者进行机械通气，根据食管压力测量调整PEEP（食管压力引导组）或根据急性呼吸窘迫综合征网络标准护理建议（对照组）。主要终点为氧合改善。次要终点包括呼吸系统顺应性和患者预后。研究达到终止标准，在入组61例患者后终止。食管压力引导组72 h动脉氧分压与吸入氧分数之比比对照组高88 mm Hg（95%可信区间为78.1 ~ 98.3;P = 0.002）。这种影响在整个随访期间持续存在（24、48和72小时；通过重复测量方差分析P = 0.001）。食管压力引导组在24、48和72小时呼吸系统顺应性也明显更好（重复测量方差分析P = 0.01）。与目前的护理标准相比，使用食管压力来估计跨肺压力的呼吸机策略可显着改善氧合和依从性。需要多中心临床试验来确定这种方法是否应该被广泛采用。（ClinicalTrials.gov编号：NCT00127491）
Survival of patients with acute lung injury or the acute respiratory distress syndrome (ARDS) has been improved by ventilation with small tidal volumes and the use of positive end-expiratory pressure (PEEP); however, the optimal level of PEEP has been difficult to determine. In this pilot study, we estimated transpulmonary pressure with the use of esophageal balloon catheters. We reasoned that the use of pleural-pressure measurements, despite the technical limitations to the accuracy of such measurements, would enable us to find a PEEP value that could maintain oxygenation while preventing lung injury due to repeated alveolar collapse or overdistention. We randomly assigned patients with acute lung injury or ARDS to undergo mechanical ventilation with PEEP adjusted according to measurements of esophageal pressure (the esophageal-pressure–guided group) or according to the Acute Respiratory Distress Syndrome Network standard-of-care recommendations (the control group). The primary end point was improvement in oxygenation. The secondary end points included respiratory-system compliance and patient outcomes. The study reached its stopping criterion and was terminated after 61 patients had been enrolled. The ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen at 72 hours was 88 mm Hg higher in the esophageal-pressure–guided group than in the control group (95% confidence interval, 78.1 to 98.3; P = 0.002). This effect was persistent over the entire follow-up time (at 24, 48, and 72 hours; P = 0.001 by repeated-measures analysis of variance). Respiratory-system compliance was also significantly better at 24, 48, and 72 hours in the esophageal-pressure–guided group (P = 0.01 by repeated-measures analysis of variance). As compared with the current standard of care, a ventilator strategy using esophageal pressures to estimate the transpulmonary pressure significantly improves oxygenation and compliance. Multicenter clinical trials are needed to determine whether this approach should be widely adopted. (ClinicalTrials.gov number, NCT00127491.)