Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries
Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries
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DOI：
10.1001/jama.2016.0291
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发表时间：
2016-02-23
影响因子：
120.7
通讯作者：
Pesenti, Antonio
中科院分区：
文献类型：
--
作者：
Bellani, Giacomo;Laffey, John G.;Pesenti, Antonio
重要性关于急性呼吸窘迫综合征（ARDS）患者的流行病学、识别、管理和结果的信息有限。目的评价重症监护病房（ICU）中ARDS的发病率和结果，并评估临床医生对符合ARDS柏林定义的患者的识别、通气管理和俯卧位的使用。了解严重急性呼吸衰竭全球影响的大型观察性研究（LUNG SAFE）是一项在接受有创或无创通气的患者中进行的国际、多中心、前瞻性队列研究，2014年冬季，在来自5大洲50个国家的459个ICU的便利样本中进行了连续4周的研究。主要结果和指标主要结果是ICU中ARDS的发生率。次要结果包括评估临床医生对ARDS的认识、急救管理的应用、常规临床实践中预防性干预的使用以及ARDS的临床结局。结果在29144例入住ICU的患者中，3022例（10.4%）符合ARDS标准。其中，2377例患者在最初48小时内发生ARDS，其呼吸衰竭采用有创机械通气治疗。轻度、中度和重度ARDS的患病率分别为30.0%（95%CI，28.2%~ 31.9%）、46.6%（95%CI，44.5%~ 48.6%）和23.4%（95%CI，21.7%~ 25.2%）。在4周内，每个ICU床位有0. 42例ARDS，占ICU入院人数的10. 4%（95% CI，10. 0%-10. 7%），占需要机械通气患者的23. 4%。ARDS的临床识别率从轻度的51.3%（95%CI，47.5%-55.0%）到重度的78.5%（95%CI，74.8%-81.8%）不等。不到三分之二的ARDS患者接受的潮气量为8 mL/kg或低于预测体重。在40.1%（95% CI，38.2-42.1）的患者中测量到平台压，而82.6%（95% CI，81.0%-84.1%）的患者接受了小于12 cm H2O的呼气末正压（PEEP）。16.3%（95% CI，13.7%-19.2%）的重度ARDS患者采用俯卧位。临床医生对ARDS的识别与较高的PEEP、更多地使用神经肌肉阻滞和俯卧位相关。住院死亡率为34.9%（95% CI，31.4%-38.5%）轻度，40.3%（95% CI，37.4%-43.3%），中度和46.1%（95%CI，41.9%-50.4%）。结论和相关性在50个国家的ICU中，ICU期间ARDS的发生率为10.4%。这种综合征似乎认识不足，治疗不足，死亡率高。这些发现表明了改善ARDS患者管理的潜力。
IMPORTANCE Limited information exists about the epidemiology, recognition, management, and outcomes of patients with the acute respiratory distress syndrome (ARDS).OBJECTIVES To evaluate intensive care unit (ICU) incidence and outcome of ARDS and to assess clinician recognition, ventilation management, and use of adjuncts-for example prone positioning-in routine clinical practice for patients fulfilling the ARDS Berlin Definition.DESIGN, SETTING, AND PARTICIPANTS The Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) was an international, multicenter, prospective cohort study of patients undergoing invasive or noninvasive ventilation, conducted during 4 consecutive weeks in the winter of 2014 in a convenience sample of 459 ICUs from 50 countries across 5 continents.EXPOSURES Acute respiratory distress syndrome.MAIN OUTCOMES AND MEASURES The primary outcome was ICU incidence of ARDS. Secondary outcomes included assessment of clinician recognition of ARDS, the application of ventilatory management, the use of adjunctive interventions in routine clinical practice, and clinical outcomes from ARDS.RESULTS Of 29 144 patients admitted to participating ICUs, 3022 (10.4%) fulfilled ARDS criteria. Of these, 2377 patients developed ARDS in the first 48 hours and whose respiratory failure was managed with invasive mechanical ventilation. The period prevalence of mild ARDS was 30.0%(95% CI, 28.2%-31.9%); of moderate ARDS, 46.6%(95% CI, 44.5%-48.6%); and of severe ARDS, 23.4%(95% CI, 21.7%-25.2%). ARDS represented 0.42 cases per ICU bed over 4 weeks and represented 10.4%(95% CI, 10.0%-10.7%) of ICU admissions and 23.4% of patients requiring mechanical ventilation. Clinical recognition of ARDS ranged from 51.3% (95% CI, 47.5%-55.0%) in mild to 78.5%(95% CI, 74.8%-81.8%) in severe ARDS. Less than two-thirds of patients with ARDS received a tidal volume 8 of mL/kg or less of predicted body weight. Plateau pressure was measured in 40.1%(95% CI, 38.2-42.1), whereas 82.6%(95% CI, 81.0%-84.1%) received a positive end-expository pressure (PEEP) of less than 12 cm H2O. Prone positioning was used in 16.3%(95% CI, 13.7%-19.2%) of patients with severe ARDS. Clinician recognition of ARDS was associated with higher PEEP, greater use of neuromuscular blockade, and prone positioning. Hospital mortality was 34.9%(95% CI, 31.4%-38.5%) for those with mild, 40.3%(95% CI, 37.4%-43.3%) for those with moderate, and 46.1%(95% CI, 41.9%-50.4%) for those with severe ARDS.CONCLUSIONS AND RELEVANCE Among ICUs in 50 countries, the period prevalence of ARDS was 10.4% of ICU admissions. This syndrome appeared to be underrecognized and undertreated and associated with a high mortality rate. These findings indicate the potential for improvement in the management of patients with ARDS.