Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation
Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation
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DOI：
10.1097/01.ccm.0000133019.52531.30
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发表时间：
2004-09-01
影响因子：
8.8
通讯作者：
Hubmayr, RD
中科院分区：
文献类型：
--
作者：
Gajic, O;Dara, SI;Hubmayr, RD
目标。虽然小潮气量的呼吸机被推荐用于已确诊的急性肺损伤患者，但大多数患者采用高度可变的潮气量，部分目的是为了使动脉血气值正常化。我们测试了这样的假设，即在机械通气开始后发生的急性肺损伤与呼吸机引起的肺损伤的已知危险因素有关，例如大潮气量的机械通气。设计：回溯性队列研究。地点：三级转诊中心的四个重症监护室。患者：在2001年1月至12月期间接受有创机械通气超过或等于48小时的患者。干预：无。测量和主要结果。主要结果是急性肺损伤，通过独立回顾每日数字胸片和动脉血气进行评估。从急性生理学和慢性健康评估III数据库和患者的医疗记录中提取呼吸机设置、血流动力学和急性肺损伤危险因素。在332名从一开始就没有急性肺损伤的患者中，80名患者(24%)在机械通气的前5天内出现了急性肺损伤。当按预计体重表示时，女性的潮气量比男性大(平均11.4毫升/千克预测体重，p<；.001)，而且更容易发生急性肺损伤(29%对20%，p=.068)。在多变量分析中，与发生急性肺损伤相关的主要危险因素是使用大潮气量(每毫升超过6毫升/公斤预计体重，优势比1.3，p<；0.001)，输血产品(优势比，3.0；p<；0.001)，酸血症(pH和7.35；优势比，2.0，p=.032)和限制性肺部疾病病史(优势比，3.6；结论：初始潮气量与急性肺损伤的发展之间的关联表明，呼吸机相关性肺损伤可能是该综合征的重要原因。在设置呼吸机时应考虑身高和性别，不仅在已确诊的急性肺损伤患者中，而且在有急性肺损伤风险的患者中，应充分考虑限制大潮气量。
Objective. Although ventilation with small tidal volumes is recommended in patients with established acute lung injury, most others receive highly variable tidal volume aimed in part at normalizing arterial blood gas values. We tested the hypothesis that acute lung injury, which develops after the initiation of mechanical ventilation, is associated with known risk factors for ventilator-induced lung injury such as ventilation with large tidal volume.Design: Retrospective cohort study.Setting: Four intensive care units in a tertiary referral center.Patients: Patients who received invasive mechanical ventilation for greater than or equal to48 hrs between January and December 2001. Interventions: None.Measurements and Main Results. The main outcome of interest, acute lung injury, was assessed by independent review of daily digital chest radiographs and arterial blood gases. Ventilator settings, hemodynamics, and acute lung injury risk factors were extracted from the Acute Physiology and Chronic Health Evaluation III database and the patients' medical records. Of 332 patients who did not have acute lung injury from the outset, 80 patients (24%) developed acute lung injury within the first 5 days of mechanical ventilation. When expressed per predicted body weight, women were ventilated with larger tidal volume than men (mean 11.4 vs. 10.4 mL/kg predicted body weight, p < .001) and tended to develop acute lung injury more often (29% vs. 20%, p =.068). In a multivariate analysis, the main risk factors associated with the development of acute lung injury were the use of large tidal volume (odds ratio 1.3 for each mL above 6 mL/kg predicted body weight, p < .001), transfusion of blood products (odds ratio, 3.0; p < 0.001), acidemia (pH < 7.35; odds ratio, 2.0; p = .032) and a history of restrictive lung disease (odds ratio, 3.6; p = .044).Conclusions: The association between the initial tidal volume and the development of acute lung injury suggests that ventilator-associated lung injury may be an important cause of this syndrome. Height and gender should be considered when setting up the ventilator, Strong consideration should be given to limiting large tidal volume, not only in patients with established acute lung injury but also in patients at risk for acute lung injury.