Risk factors for the development of acute respiratory distress syndrome in mechanically ventilated adults in Peru: a multicenter observational study
Risk factors for the development of acute respiratory distress syndrome in mechanically ventilated adults in Peru: a multicenter observational study
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DOI：
10.1186/s13054-019-2646-8
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发表时间：
2019-12-06
期刊：
影响因子：
15.1
通讯作者：
Pereda, Maria Alejandra
中科院分区：
文献类型：
--
作者：
Gupta, Ena;Hossen, Shakir;Pereda, Maria Alejandra
背景 机械通气 [MV] 开始时出现的急性呼吸窘迫综合征 (ARDS)（MV 发作时的 ARDS）与 MV 过程中出现的急性呼吸窘迫综合征（MV 发作后的 ARDS）之间的临床和流行病学差异尚不清楚。我们在五个秘鲁 ICU 中进行了一项观察性研究，以描述 MV 发作时和 MV 发作后 ARDS 之间的差异，并确定 MV 发作后发生 ARDS 的危险因素。方法 我们连续入组需要至少 24 小时机械通气的急性呼吸衰竭危重患者，并在前 28 天内进行前瞻性随访，并按 ARDS 状态比较基线特征和临床结果。结果 我们招募了 1657 名 MV 参与者（平均年龄 60.0 岁，55% 男性），其中 334 名（20.2%）在 MV 发病时患有 ARDS，180 名（10.9%）在 MV 发病后出现 ARDS。对于 MV 开始时发生 ARDS 的参与者，MV 开始时的平均潮气量为 8.7 mL/kg 预计体重 (PBW)，对于 MV 发生后发生 ARDS 的参与者，平均潮气量为 8.6 mL/kg PBW，对于从未发生 ARDS 的参与者，平均潮气量为 8.5 mL/kg PBW (p = 0.23)。总体而言，MV 发病后 ARDS 和 MV 发病时 ARDS 的 90 天死亡率分别为 56% 和 55%，而从未发生 ARDS 的患者的 90 天死亡率为 46% (p < 0.01)。患有 ARDS 的成年人的体重指数 (BMI) 高于未患有 ARDS 的成年人（27.3 vs 26.5 kg/m(2)，p < 0.01）。 MV 开始时较高的峰值压力（调整后的四分位间 OR = 1.51，95% CI 1.21-1.88）、较高的平均气道压力（调整后的四分位间 OR = 1.41，95% CI 1.13-1.76）和较高的呼气末正压（调整后的四分位间 OR = 1.29，95% CI 1.10-1.50）与 MV 发生相关。 MV 发作后发生 ARDS 的几率更高。结论 在这项针对机械通气患者的研究中，31% 的研究参与者在 ICU 住院期间的某个时间点患有 ARDS。大多数患者没有使用最佳的肺保护通气。 MV 发作后发生 ARDS 的患者的 90 天死亡率与 MV 发生时发生 ARDS 的患者相似。 MV 发作时较高的气道压力、较高的 PEEP 和较高的 BMI 与 MV 发作后发生 ARDS 相关。
Background Clinical and epidemiological differences between acute respiratory distress syndrome (ARDS) that presents at the initiation of mechanical ventilation [MV] (ARDS at MV onset) and that which develops during the course of MV (ARDS after MV onset) are not well understood. We conducted an observational study in five Peruvian ICUs to characterize differences between ARDS at MV onset and after MV onset and identify risk factors for the development of ARDS after MV onset. Methods We consecutively enrolled critically ill patients with acute respiratory failure requiring at least 24 h of mechanical ventilation and followed them prospectively during the first 28 days and compared baseline characteristics and clinical outcomes by ARDS status. Results We enrolled 1657 participants on MV (mean age 60.0 years, 55% males) of whom 334 (20.2%) had ARDS at MV onset and 180 (10.9%) developed ARDS after MV onset. Average tidal volume at the initiation of MV was 8.7 mL/kg of predicted body weight (PBW) for participants with ARDS at MV onset, 8.6 mL/kg PBW for those who developed ARDS after MV onset, and 8.5 mL/kg PBW for those who never developed ARDS (p = 0.23). Overall, 90-day mortality was 56% and 55% for ARDS after MV onset and ARDS at MV onset, respectively, as compared to 46% among those who never developed ARDS (p < 0.01). Adults with ARDS had a higher body mass index (BMI) than those without ARDS (27.3 vs 26.5 kg/m(2), p < 0.01). Higher peak pressure (adjusted interquartile OR = 1.51, 95% CI 1.21-1.88), higher mean airway pressure (adjusted interquartile OR = 1.41, 95% CI 1.13-1.76), and higher positive end-expiratory pressure (adjusted interquartile OR = 1.29, 95% CI 1.10-1.50) at MV onset were associated with a higher odds of developing ARDS after MV onset. Conclusions In this study of mechanically ventilated patients, 31% of study participants had ARDS at some point during their ICU stay. Optimal lung-protective ventilation was not used in a majority of patients. Patients with ARDS after MV onset had a similar 90-day mortality as those with ARDS at MV onset. Higher airway pressures at MV onset, higher PEEP, and higher BMI were associated with the development of ARDS after MV onset.