Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome - A randomized controlled trial
Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome - A randomized controlled trial
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DOI：
10.1001/jama.299.6.646
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发表时间：
2008-02-13
影响因子：
120.7
通讯作者：
Brochard, Laurent
中科院分区：
文献类型：
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作者：
Mercat, Alain;Richard, Jean-Christophe M.;Brochard, Laurent
肺保护的必要性是普遍接受的，但急性肺损伤（ALI）或急性呼吸窘迫综合征患者呼气末正压（PEEP）的最佳水平仍存在争议。目的比较ALI患者设置以增加肺泡恢复为目的的PEEP与以减少肺泡扩张为目的的PEEP的效果。设计、环境和患者：2002年9月至2005年12月，在法国37个重症监护病房进行了一项多中心随机对照试验，767名患有ALI的成年人（平均[SD]年龄59.9[15.4]岁）。在两种策略中潮汐量均设定为6 mL/ kg预测体重。患者被随机分配到中度PEEP策略（5- 9 cm H2O）（最小扩张策略，n= 382）或达到平台压力28 - 30 cm H2O的PEEP水平（增加招募策略，n= 385）。主要终点为28天死亡率。次要终点是60天的住院死亡率、无呼吸机天数和28天无器官衰竭天数。结果最小膨胀组28天死亡率为31.2% (n= 119)，而增加招募组28天死亡率为27.8% (n= 107)(相对危险度为1.12[95%可信区间，0.90 ~ 1.40]；31)。最小膨胀组的住院死亡率为39.0% (n= 149)，而增加招募组的住院死亡率为35.4% (n= 136)(相对危险度为1.10[95%可信区间，0.92- 1.32]；30)。与最小扩张组相比，增加招募组无呼吸机天数中位数更高(7[四分位数间距{IQR}， 0- 19]比3 [IQR， 0- 17]； P=。4)和无器官衰竭天数(6 [IQR, 0- 18] vs 2 [IQR, 0- 16]； P=。04)。该策略还与更高的顺应性值、更好的氧合、更少的辅助治疗使用和更大的液体需求相关。结论：设定PEEP的策略旨在增加肺泡再扩张，同时限制恶性充气，并不能显著降低死亡率。然而，它确实改善了肺功能，缩短了机械通气的时间和器官衰竭的持续时间。试验注册临床试验。标识符：NCT00188058。
Context The need for lung protection is universally accepted, but the optimal level of positive end- expiratory pressure ( PEEP) in patients with acute lung injury ( ALI) or acute respiratory distress syndrome remains debated.Objective To compare the effect on outcome of a strategy for setting PEEP aimed at increasing alveolar recruitment while limiting hyperinflation to one aimed at minimizing alveolar distension in patients with ALI.Design, Setting, and Patients A multicenter randomized controlled trial of 767 adults ( mean [ SD] age, 59.9 [ 15.4] years) with ALI conducted in 37 intensive care units in France from September 2002 to December 2005.Intervention Tidal volume was set at 6 mL/ kg of predicted body weight in both strategies. Patients were randomly assigned to a moderate PEEP strategy ( 5- 9 cm H2O) ( minimal distension strategy; n= 382) or to a level of PEEP set to reach a plateau pressure of 28 to 30 cm H2O ( increased recruitment strategy; n= 385).Main Outcome Measures The primary end point was mortality at 28 days. Secondary end points were hospital mortality at 60 days, ventilator- free days, and organ failure - free days at 28 days.Results The 28- day mortality rate in the minimal distension group was 31.2% ( n= 119) vs 27.8% ( n= 107) in the increased recruitment group ( relative risk, 1.12 [ 95% confidence interval, 0.90- 1.40]; P=. 31). The hospital mortality rate in the minimal distension group was 39.0% ( n= 149) vs 35.4% ( n= 136) in the increased recruitment group ( relative risk, 1.10 [ 95% confidence interval, 0.92- 1.32]; P=. 30). The increased recruitment group compared with the minimal distension group had a higher median number of ventilator- free days ( 7 [ interquartile range {IQR}, 0- 19] vs 3 [ IQR, 0- 17]; P=. 04) and organ failure - free days ( 6 [ IQR, 0- 18] vs 2 [ IQR, 0- 16]; P=. 04). This strategy also was associated with higher compliance values, better oxygenation, less use of adjunctive therapies, and larger fluid requirements.Conclusions A strategy for setting PEEP aimed at increasing alveolar recruitment while limiting hyperinflation did not significantly reduce mortality. However, it did improve lung function and reduced the duration of mechanical ventilation and the duration of organ failure.Trial Registration clinicaltrials. gov Identifier: NCT00188058.