Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome.
Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome.
复制标题
急性呼吸窘迫综合征患者呼气末正压较高与较低。
DOI：
10.1056/nejmoa032193
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发表时间：
2004
期刊：
影响因子：
--
通讯作者：
NationalHeart,Lung,andBloodInstituteARDSClinicalTrialsNetwork
中科院分区：
文献类型：
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作者：
Brower,RoyG;Lanken,PaulN;MacIntyre,Neil;Matthay,MichaelA;Morris,Alan;Ancukiewicz,Marek;Schoenfeld,David;Thompson,BTaylor;NationalHeart,Lung,andBloodInstituteARDSClinicalTrialsNetwork
背景 大多数因急性肺损伤和急性呼吸窘迫综合征 (ARDS) 需要机械通气的患者接受 5 至 12 厘米水柱的呼气末正压 (PEEP)。较高的 PEEP 水平可以改善氧合并减少呼吸机引起的肺损伤，但也可能导致循环抑制和过度扩张引起的肺损伤。我们进行这项试验的目的是比较较高和较低 PEEP 水平对这些患者临床结果的影响。方法我们随机分配 549 名患有急性肺损伤和 ARDS 的患者接受较低或较高 PEEP 水平的机械通气，这是根据 PEEP 和吸入氧分数的预定组合的不同表格设置的。结果第 1 天至第 4 天的平均 (±SD) PEEP 值是 较低 PEEP 组为 8.3±3.2 cm 水柱，较高 PEEP 组为 13.2±3.5 cm 水柱（P<0.001）。出院前死亡率分别为 24.9% 和 27.5%（P=0.48；组间差异的 95% 置信区间为 –10.0% 至 4.7%）。从第 1 天到第 28 天，低 PEEP 组平均无辅助呼吸时间为 14.5±10.4 天，高 PEEP 组平均无辅助呼吸时间为 13.8±10.6 天（P=0.50）。结论这些结果表明，在接受机械通气的急性肺损伤和 ARDS 患者中，潮气量目标为每公斤预测体重 6 ml，吸气末平台压限制为 30 厘米水深，无论使用较低还是较高的 PEEP 水平，临床结果相似。
BackgroundMost patients requiring mechanical ventilation for acute lung injury and the acute respiratory distress syndrome (ARDS) receive positive end-expiratory pressure (PEEP) of 5 to 12 cm of water. Higher PEEP levels may improve oxygenation and reduce ventilator-induced lung injury but may also cause circulatory depression and lung injury from overdistention. We conducted this trial to compare the effects of higher and lower PEEP levels on clinical outcomes in these patients.MethodsWe randomly assigned 549 patients with acute lung injury and ARDS to receive mechanical ventilation with either lower or higher PEEP levels, which were set according to different tables of predetermined combinations of PEEP and fraction of inspired oxygen.ResultsMean (±SD) PEEP values on days 1 through 4 were 8.3±3.2 cm of water in the lower-PEEP group and 13.2±3.5 cm of water in the higher-PEEP group (P<0.001). The rates of death before hospital discharge were 24.9 percent and 27.5 percent, respectively (P=0.48; 95 percent confidence interval for the difference between groups, –10.0 to 4.7 percent). From day 1 to day 28, breathing was unassisted for a mean of 14.5±10.4 days in the lower-PEEP group and 13.8±10.6 days in the higher-PEEP group (P=0.50).ConclusionsThese results suggest that in patients with acute lung injury and ARDS who receive mechanical ventilation with a tidal-volume goal of 6 ml per kilogram of predicted body weight and an end-inspiratory plateau-pressure limit of 30 cm of water, clinical outcomes are similar whether lower or higher PEEP levels are used.