Effect of Lowering VT on Mortality in Acute Respiratory Distress Syndrome Varies with Respiratory System Elastance
Effect of Lowering VT on Mortality in Acute Respiratory Distress Syndrome Varies with Respiratory System Elastance
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DOI：
10.1164/rccm.202009-3536oc
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发表时间：
2021-06-01
影响因子：
24.7
通讯作者：
Amato, Marcelo P. B.
中科院分区：
文献类型：
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作者：
Goligher, Ewan C.;Costa, Eduardo L., V;Amato, Marcelo P. B.
基本原理：如果急性呼吸窘迫综合征（ARDS）中呼吸机相关肺损伤的风险是由驱动压力而不是V-T决定的，那么低V-T通气对死亡率的影响将根据呼吸系统弹性（Ers）而变化。目的：确定低V-T通气的死亡率获益是否根据Ers而变化。方法：在对来自5项ARDS和急性低氧性呼吸衰竭患者的低V-T通气策略与高V-T通气策略的随机试验的二次分析中，使用贝叶斯多变量逻辑回归计算随机V-T策略与60天死亡率Ers之间相互作用的后验概率。在可用于分析的1，096例患者中，416例（38%）在第60天死亡。低V-T通气策略的死亡率获益随Ers变化的后验概率为93%（后验中位数相互作用比值比，0.80/cm H2O/[ml/kg]; 90%可信区间，0.63-1.02）。Ers被归类为低（3 cm H2O/[ml/kg]，n=224，22%）。在这些组中，死亡率>= 1%的绝对风险降低的后验概率分别为55%、82%和92%。绝对风险降低≥ 5%的后验概率分别为29%、58%和82%，respectively.Conclusions：ARDS患者低V-T通气的死亡率获益因弹性而异，提示肺保护性通气策略应主要针对驱动压而非V-T。
Rationale: If the risk of ventilator-induced lung injury in acute respiratory distress syndrome (ARDS) is causally determined by driving pressure rather than by V-T, then the effect of ventilation with lower V-T on mortality would be predicted to vary according to respiratory system elastance (Ers).Objectives: To determine whether the mortality benefit of ventilation with lower V-T varies according to Ers.Methods: In a secondary analysis of patients from five randomized trials of lower-versus higher-V-T ventilation strategies in ARDS and acute hypoxemic respiratory failure, the posterior probability of an interaction between the randomized V-T strategy and Ers on 60-day mortality was computed using Bayesian multivariable logistic regression.Measurements and Main Results: Of 1,096 patients available for analysis, 416 (38%) died by Day 60. The posterior probability that the mortality benefit from lower-V-T ventilation strategies varied with Ers was 93% (posterior median interaction odds ratio, 0.80 per cm H2O/[ml/kg]; 90% credible interval, 0.63-1.02). Ers was classified as low (3 cm H2O/[ml/kg], n=224, 22%). In these groups, the posterior probabilities of an absolute risk reduction in mortality >= 1% were 55%, 82%, and 92%, respectively. The posterior probabilities of an absolute risk reduction >= 5% were 29%, 58%, and 82%, respectively.Conclusions: The mortality benefit of ventilation with lower V-T in ARDS varies according to elastance, suggesting that lungprotective ventilation strategies should primarily target driving pressure rather than V-T.