Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome A Randomized Clinical Trial
Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome A Randomized Clinical Trial
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DOI：
10.1001/jama.2017.14171
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发表时间：
2017-10-10
影响因子：
120.7
通讯作者：
Ribeiro de Carvalho, Carlos Roberto
中科院分区：
文献类型：
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作者：
Cavalcanti, Alexandre Biasi;Suzumura, Erica Aranha;Ribeiro de Carvalho, Carlos Roberto
肺复张策略和呼气末正压（PEEP）滴定对急性呼吸窘迫综合征（ARDS）患者临床结局的影响尚不确定。目的：确定肺复张与根据最佳呼吸系统顺应性进行PEEP滴定相结合是否能降低中重度ARDS患者28天的死亡率，与常规低PEEP策略相比。与参与者2011年11月17日至2017年4月25日在9个国家的120个重症监护病房（ICU）进行的多中心随机试验，招募中重度ARDS成人患者。干预根据最佳呼吸系统依从性，采用肺复张策略和PEEP滴定的实验策略（n = 501;实验组）或低PEEP的对照策略（n = 509）。所有患者均接受容量辅助控制模式，直至撤机。主要结局和指标主要结局为28天内的全因死亡率。次要结果是ICU和住院时间的长度;到第28天的无呼吸机天数; 7天内需要引流的气胸; 7天内的气压伤;以及ICU、住院和6个月的死亡率。结果共1010例患者（37.5%女性;平均[SD]年龄，50.9 [17.4]岁）入选并随访。第28天，实验组501例患者中有277例（55.3%）死亡，对照组509例患者中有251例（49.3%）死亡（风险比[HR]，1.20; 95% CI，1.01 - 1.42; P = 0.041）。与对照组相比，实验组策略增加了6个月死亡率（65.3% vs 59.9%; HR，1.18; 95% CI，1.01 - 1.38; P =.04），平均无呼吸机天数减少（5.3 vs 6.4;差异，-1.1; 95% CI，-2.1至-0.1; P = 0.03），增加了需要引流的气胸风险（3.2% vs 1.2%;差异，2.0%; 95% CI，0.0%至4.0%; P = 0.03）和气压伤风险（5.6% vs 1.6%;差异，4.0%; 95% CI，1.5%至6.5%; P = 0.001）。ICU住院时间、住院时间、ICU死亡率和院内死亡率无显著差异。结论和相关性在中度至重度ARDS患者中，肺复张和滴定PEEP策略与低PEEP相比增加了28天全因死亡率。这些结果不支持在这些患者中常规使用肺复张策略和PEEP滴定。(C)2017年美国医学会。All rights reserved.
IMPORTANCE The effects of recruitment maneuvers and positive end-expiratory pressure (PEEP) titration on clinical outcomes in patients with acute respiratory distress syndrome (ARDS) remain uncertain.OBJECTIVE To determine if lung recruitment associated with PEEP titration according to the best respiratory-system compliance decreases 28-day mortality of patients with moderate to severe ARDS compared with a conventional low-PEEP strategy.DESIGN, SETTING, AND PARTICIPANTS Multicenter, randomized trial conducted at 120 intensive care units (ICUs) from 9 countries from November 17, 2011, through April 25, 2017, enrolling adults with moderate to severe ARDS.INTERVENTIONS An experimental strategy with a lung recruitment maneuver and PEEP titration according to the best respiratory-system compliance (n = 501; experimental group) or a control strategy of low PEEP (n = 509). All patients received volume-assist control mode until weaning.MAIN OUTCOMES AND MEASURES The primary outcomewas all-cause mortality until 28 days. Secondary outcomes were length of ICU and hospital stay; ventilator-free days through day 28; pneumothorax requiring drainage within 7 days; barotrauma within 7 days; and ICU, in-hospital, and 6-month mortality.RESULTS A total of 1010 patients (37.5% female; mean [SD] age, 50.9 [17.4] years) were enrolled and followed up. At 28 days, 277 of 501 patients (55.3%) in the experimental group and 251 of 509 patients (49.3%) in the control group had died (hazard ratio [HR], 1.20; 95% CI, 1.01 to 1.42; P =.041). Compared with the control group, the experimental group strategy increased 6-month mortality (65.3% vs 59.9%; HR, 1.18; 95% CI, 1.01 to 1.38; P =.04), decreased the number of mean ventilator-free days (5.3 vs 6.4; difference, -1.1; 95% CI, -2.1 to -0.1; P =.03), increased the risk of pneumothorax requiring drainage (3.2% vs 1.2%; difference, 2.0%; 95% CI, 0.0% to 4.0%; P =.03), and the risk of barotrauma (5.6% vs 1.6%; difference, 4.0%; 95% CI, 1.5% to 6.5%; P =.001). There were no significant differences in the length of ICU stay, length of hospital stay, ICU mortality, and in-hospital mortality.CONCLUSIONS AND RELEVANCE In patients with moderate to severe ARDS, a strategy with lung recruitment and titrated PEEP compared with low PEEP increased 28-day all-cause mortality. These findings do not support the routine use of lung recruitment maneuver and PEEP titration in these patients. (C) 2017 American Medical Association. All rights reserved.