Severity of Hypoxemia and Other Factors That Influence the Response to Aerosolized Prostacyclin in ARDS
Severity of Hypoxemia and Other Factors That Influence the Response to Aerosolized Prostacyclin in ARDS
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DOI：
10.4187/respcare.05268
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发表时间：
2017-08-01
期刊：
影响因子：
2.5
通讯作者：
Lipnick, Michael S.
中科院分区：
文献类型：
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作者：
Kallet, Richard H.;Burns, Gregory;Lipnick, Michael S.
背景：ARDS的特点是功能残气量(FRC)降低、异质性肺损伤和严重低氧血症。潮气式呼吸机优先分配给有呼吸机的肺泡。雾化前列腺素I-2通过诱导局部血管扩张来利用这一病理生理学机制，从而增加通风-灌流匹配，减少低氧血症。因此，雾化前列腺素I-2的疗效可能取决于FRC。P-AO2/F-IO2和呼吸系统顺应性(C-RS)都是FRC的间接标志，因此可能部分决定了对雾化前列腺素I-2的反应。方法：我们回顾了208例ARDS患者，他们接受前列腺素I-2雾化治疗，并在治疗开始前和治疗后进行了动脉血气监测，而没有进行其他呼吸机操作。受试者根据基线P-AO2/F-IO2(最低：60，中等：60-90，最高：90 mm Hg)和C-RS(<；20，20-29，30-39，和>；=40mL/cm H2O)以及其他因素(如脓毒症)进行分组。比较分析采用配对t检验，或Kruskal-Wallis和Dunn后验。采用多变量Logistic回归模型来确定18个临床相关因素中哪一个对雾化前列腺素I-2的反应最具预测性。阿尔法被设定为0.05。结果：前列腺素I-2治疗后，P-AO2/F-IO2平均升高33 mm Hg(42%)，有效率为62%。各给氧组P-AO2/F-IO2均显著升高。最高基线P-AO2/F-IO2组的改善和有效率最大(51+/-63 mm Hg，82%)。此外，有脓毒症的患者的P-AO2/F-IO2较无脓毒症的患者改善较小(18+/-35vs40+/-55 mm Hg，P=0.002)。P-AO2/F-IO2和应答率均随C-RS改善而增加，但组间改善不一致。在最终的模型中，预测雾化前列腺素I-2的阳性反应的唯一因素是基线P-AO2/F-IO2(优势比1.1[1.004-1.205]，P=0.042)和C-RS(优势比1.04[1.01-1.08]，P=0.02)。结论：雾化前列腺素I-2改善了大约60%ARDS患者的氧合。良好的反应与基线P-AO2/F-IO2和C-RS密切相关。
BACKGROUND: ARDS is characterized by decreased functional residual capacity (FRC), heterogeneous lung injury, and severe hypoxemia. Tidal ventilation is preferentially distributed to ventilated alveoli. Aerosolized prostaglandin I-2 exploits this pathophysiology by inducing local vasodilation, thereby increasing ventilation-perfusion matching and reducing hypoxemia. Therefore, aerosolized prostaglandin I-2 efficacy may depend upon FRC. Both P-aO2/F-IO2 and compliance of the respiratory system (C-RS) are indirect signifiers of FRC and thus may partly determine the response to aerosolized prostaglandin I-2. METHODS: We reviewed the records of 208 ARDS subjects who received aerosolized prostaglandin I-2 and had arterial blood gases done before and after the initiation of therapy, without other ventilator manipulations. Subjects were grouped according to baseline P-aO2/F-IO2 (lowest: < 60, intermediate: 60-90, highest: > 90 mm Hg) and C-RS (< 20, 20-29, 30-39, and >= 40 mL/cm H2O) and by other factors, such as sepsis. Comparisons were analyzed by paired t tests, or Kruskal-Wallis and Dunn post-tests. Multivariate logistic regression modeling was done to determine which of 18 clinically relevant factors were most predictive for responding to aerosolized prostaglandin I-2. alpha was set at .05. RESULTS: Mean P-aO2/F-IO2 increased by 33 mm Hg (42%) upon initiation of prostaglandin I-2, with a responder rate of 62%. P-aO2/F-IO2 increased significantly in all oxygenation groups. The highest baseline P-aO2/F-IO2 group had the greatest improvement and responder rate (51 +/- 63 mm Hg, and 82%). In addition, those with sepsis had a smaller improvement in P-aO2/F-IO2 compared with those without sepsis (18 +/- 35 vs 40 +/- 55 mm Hg, P = .002). Both P-aO2/F-IO2 and responder rate increased as C-RS improved, but between-group improvements were not as consistent. In the final model, the only factors that predicted a positive response to aerosolized prostaglandin I-2 were baseline P-aO2/F-IO2 (odds ratio 1.10 [1.004-1.205], P = .042) and C-RS (odds ratio 1.04 [1.01-1.08], P = .02). CONCLUSIONS: Aerosolized prostaglandin I-2 improves oxygenation in approximately 60% of ARDS cases. A favorable response was most strongly associated with baseline P-aO2/F-IO2 and C-RS.