Pathophysiology of COVID-19-associated acute respiratory distress syndrome: a multicentre prospective observational study.
Pathophysiology of COVID-19-associated acute respiratory distress syndrome: a multicentre prospective observational study.
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DOI：
10.1016/s2213-2600(20)30370-2
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发表时间：
2020-12
期刊：
影响因子：
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通讯作者：
collaborators
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作者：
Grasselli G;Tonetti T;Protti A;Langer T;Girardis M;Bellani G;Laffey J;Carrafiello G;Carsana L;Rizzuto C;Zanella A;Scaravilli V;Pizzilli G;Grieco DL;Di Meglio L;de Pascale G;Lanza E;Monteduro F;Zompatori M;Filippini C;Locatelli F;Cecconi M;Fumagalli R;Nava S;Vincent JL;Antonelli M;Slutsky AS;Pesenti A;Ranieri VM;collaborators
COVID-19患者可发展为急性呼吸窘迫综合征（ARDS），这与高死亡率相关。本研究的目的是检查COVID-19相关ARDS的功能和形态学特征，并将其与COVID-19无关的ARDS特征进行比较。这项前瞻性观察性研究在意大利的七家医院进行。我们招募了连续的机械通气患者，这些患者患有实验室确诊的COVID-19，符合柏林ARDS标准，于2020年3月9日至3月22日期间入住重症监护室（ICU）。所有患者均采用标准ICU呼吸机在容量控制模式下进行镇静、麻痹和通气。静态呼吸系统的顺应性，动脉氧分压的比率，吸入空气中的氧浓度分数，呼吸比（死腔的替代品），和D-二聚体浓度在ICU入院后24小时内进行了测量。当有临床指征时，进行肺部CT扫描和CT血管造影。从先前的ARDS研究中创建了与COVID-19无关的ARDS数据集。评估至第28天的存活率。2020年3月9日至3月22日期间，参与医院的301名COVID-19患者符合柏林ARDS标准。中位静态顺应性为41 mL/cm H2O（33-52），比与COVID-19无关的ARDS患者队列高28%（32 mL/cm H2O [25-43]; p<0.0001）。297例COVID-19相关ARDS患者中有17例（6%）的依从性大于经典ARDS队列的第95百分位数。两个队列之间的总肺重量没有差异。CT肺血管造影（在23例[8%] COVID-19相关ARDS患者中获得）显示，16例D-二聚体浓度大于中位数的患者中有15例（94%）存在双侧低灌注区域，与血栓栓塞性疾病一致。D-二聚体浓度等于或小于中位数的患者的死亡率低于D-二聚体浓度大于中位数的患者（1.66 [1.32 - 1.95] vs 1.90 [1.50 - 2.33]; p= 0.0001）。与其他患者亚组相比，静态顺应性等于或小于中位数且D-二聚体浓度大于中位数的患者28天死亡率显著增加（71例高D-二聚体和低顺应性患者中有40例[56%]，67例低D-二聚体和高顺应性患者中有18例[27%]，60例低D-二聚体和低顺应性患者中有13例[22%]，63例高D-二聚体和高依从性患者中有22例[35%]，所有p= 0.0001）。COVID-19相关ARDS患者的损伤形式在许多方面与COVID-19无关的ARDS患者相似。值得注意的是，患有COVID-19相关ARDS的患者，如果呼吸系统顺应性降低，同时D-二聚体浓度升高，则死亡率较高。没有。
Patients with COVID-19 can develop acute respiratory distress syndrome (ARDS), which is associated with high mortality. The aim of this study was to examine the functional and morphological features of COVID-19-associated ARDS and to compare these with the characteristics of ARDS unrelated to COVID-19. This prospective observational study was done at seven hospitals in Italy. We enrolled consecutive, mechanically ventilated patients with laboratory-confirmed COVID-19 and who met Berlin criteria for ARDS, who were admitted to the intensive care unit (ICU) between March 9 and March 22, 2020. All patients were sedated, paralysed, and ventilated in volume-control mode with standard ICU ventilators. Static respiratory system compliance, the ratio of partial pressure of arterial oxygen to fractional concentration of oxygen in inspired air, ventilatory ratio (a surrogate of dead space), and D-dimer concentrations were measured within 24 h of ICU admission. Lung CT scans and CT angiograms were done when clinically indicated. A dataset for ARDS unrelated to COVID-19 was created from previous ARDS studies. Survival to day 28 was assessed. Between March 9 and March 22, 2020, 301 patients with COVID-19 met the Berlin criteria for ARDS at participating hospitals. Median static compliance was 41 mL/cm H2O (33–52), which was 28% higher than in the cohort of patients with ARDS unrelated to COVID-19 (32 mL/cm H2O [25–43]; p<0·0001). 17 (6%) of 297 patients with COVID-19-associated ARDS had compliances greater than the 95th percentile of the classical ARDS cohort. Total lung weight did not differ between the two cohorts. CT pulmonary angiograms (obtained in 23 [8%] patients with COVID-19-related ARDS) showed that 15 (94%) of 16 patients with D-dimer concentrations greater than the median had bilateral areas of hypoperfusion, consistent with thromboembolic disease. Patients with D-dimer concentrations equal to or less than the median had ventilatory ratios lower than those of patients with D-dimer concentrations greater than the median (1·66 [1·32–1·95] vs 1·90 [1·50–2·33]; p=0·0001). Patients with static compliance equal to or less than the median and D-dimer concentrations greater than the median had markedly increased 28-day mortality compared with other patient subgroups (40 [56%] of 71 with high D-dimers and low compliance vs 18 [27%] of 67 with low D-dimers and high compliance, 13 [22%] of 60 with low D-dimers and low compliance, and 22 [35%] of 63 with high D-dimers and high compliance, all p=0·0001). Patients with COVID-19-associated ARDS have a form of injury that, in many aspects, is similar to that of those with ARDS unrelated to COVID-19. Notably, patients with COVID-19-related ARDS who have a reduction in respiratory system compliance together with increased D-dimer concentrations have high mortality rates. None.