Discordance Between Respiratory Drive and Sedation Depth in Critically Ill Patients Receiving Mechanical Ventilation.
Discordance Between Respiratory Drive and Sedation Depth in Critically Ill Patients Receiving Mechanical Ventilation.
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DOI：
10.1097/ccm.0000000000005113
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发表时间：
2021-12-01
影响因子：
8.8
通讯作者：
Beitler JR
中科院分区：
文献类型：
--
作者：
Dzierba AL;Khalil AM;Derry KL;Madahar P;Beitler JR
在机械通气患者中，深度镇静通常被认为是诱导呼吸松解，即松解自主呼吸努力，而轻度镇静通常被认为是保留自主努力。本研究旨在确定这些常见假设的有效性，评估急性呼吸衰竭患者呼吸驱动与镇静深度和无呼吸机天数的相关性。前瞻性队列研究。患者在2016-2017年的两个月期间从代表美国学术医院的内科、外科和心脏专科的五个ICU入组。合格患者是在入组前≤ 36小时开始接受有创通气的危重成人。排除了神经肌肉疾病损害呼吸功能或呼气流量受限的患者。通过P0.1测量呼吸驱动，P0.1是在患者吸气努力开始时0.1秒气道阻塞期间气道压力的变化，每12 ± 3小时测量一次，持续3天。通过里士满激动-镇静量表（RASS）评价镇静深度。分析评价了P0.1与RASS（主要结局）和无呼吸机天数的相关性。纳入了在5个重症监护病房接受197次床旁评价的五十六例患者。P0.1范围为0-13.3（中位数0.1，四分位数间距0.0-1.3）cm H2O。P0.1与RASS无显著相关性（RSpearman 0.02，95% CI-0.12 - 0.16; p = 0.80）。考虑到P0.1特厘（范围< 0.2、0.2-1.0和> 1.0 cm H2O），中三分位数患者的无呼吸机天数显著多于最低三分位数患者（发病率比[IRR] 0.78，95% CI 0.65-0.93; p < 0.01）或最高三分位数（IRR 0.58，95% CI 0.48-0.70; p < 0.01）。镇静深度不是危重病期间呼吸驱动的可靠标志。在常规目标镇静深度范围内，呼吸驱动可以是低、中或高。
In mechanically ventilated patients, deep sedation is often assumed to induce respirolysis, i.e. lyse spontaneous respiratory effort, while light sedation is often assumed to preserve spontaneous effort. This study was conducted to determine validity of these common assumptions, evaluating the association of respiratory drive with sedation depth and ventilator-free days in acute respiratory failure. Prospective cohort study. Patients were enrolled during two month-long periods in 2016–2017 from five ICUs representing medical, surgical, and cardiac specialties at a U.S. academic hospital. Eligible patients were critically ill adults receiving invasive ventilation initiated ≤ 36 hours before enrollment. Patients with neuromuscular disease compromising respiratory function or expiratory flow limitation were excluded. Respiratory drive was measured via P0.1, the change in airway pressure during a 0.1-second airway occlusion at initiation of patient inspiratory effort, every 12 ± 3 hours for 3 days. Sedation depth was evaluated via the Richmond agitation-sedation scale (RASS). Analyses evaluated the association of P0.1 with RASS (primary outcome) and ventilator-free days. Fifty-six patients undergoing 197 bedside evaluations across five intensive care units were included. P0.1 ranged between 0–13.3 (median 0.1, interquartile range 0.0–1.3) cm H2O. P0.1 was not significantly correlated with RASS (RSpearman 0.02, 95% CI −0.12 to 0.16; p = 0.80). Considering P0.1 terciles (range < 0.2, 0.2–1.0, and > 1.0 cm H2O), patients in the middle tercile had significantly more ventilator-free days than the lowest tercile (incidence rate ratio [IRR] 0.78, 95% CI 0.65–0.93; p < 0.01) or highest tercile (IRR 0.58, 95% CI 0.48–0.70; p < 0.01). Sedation depth is not a reliable marker of respiratory drive during critical illness. Respiratory drive can be low, moderate, or high across the range of routinely targeted sedation depth.