Phenotypes based on respiratory drive and effort to identify the risk factors when P0.1 fails to estimate ∆P_ES in ventilated children.

IF 8.8 1区医学 Q1 CRITICAL CARE MEDICINE

Critical Care Pub Date : 2024-10-04 DOI:10.1186/s13054-024-05103-x

Meryl Vedrenne-Cloquet, Y Ito, J Hotz, M J Klein, M Herrera, D Chang, A K Bhalla, C J L Newth, R G Khemani

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引用次数: 0

Abstract

Background: Monitoring respiratory effort and drive during mechanical ventilation is needed to deliver lung and diaphragm protection. Esophageal pressure (∆P_ES) is the gold standard measure of respiratory effort but is not routinely available. Airway occlusion pressure in the first 100 ms of the breath (P0.1) is a readily available surrogate for both respiratory effort and drive but is only modestly correlated with ∆P_ES in children. We sought to identify risk factors for P0.1 over or underestimating ∆P_ES in ventilated children.

Methods: Secondary analysis of physiological data from children and young adults enrolled in a randomized controlled trial testing lung and diaphragm protective ventilation in pediatric acute respiratory distress syndrome (PARDS) (NCT03266016). ∆P_ES (∆P_ES-REAL), P0.1 and predicted ∆P_ES (∆P_ES-PRED = 5.91*P0.1) were measured daily to identify phenotypes based upon the level of respiratory effort and drive: one passive (no spontaneous breathing), three where ∆P_ES-REAL and ∆P_ES-PRED were aligned (low, normal, and high effort and drive), two where ∆P_ES-REAL and ∆P_ES-PRED were mismatched (high underestimated effort, and overestimated effort). Logistic regression models were used to identify factors associated with each mismatch phenotype (High underestimated effort, or overestimated effort) as compared to all other spontaneous breathing phenotypes.

Results: We analyzed 953 patient days (222 patients). ∆P_ES-REAL and ∆P_ES-PRED were aligned in 536 (77%) of the active patient days. High underestimated effort (n = 119 (12%)) was associated with higher airway resistance (adjusted OR 5.62 (95%CI 2.58, 12.26) per log unit increase, p < 0.001), higher tidal volume (adjusted OR 1.53 (95%CI 1.04, 2.24) per cubic unit increase, p = 0.03), higher opioid use (adjusted OR 2.4 (95%CI 1.12, 5.13, p = 0.024), and lower set ventilator rate (adjusted OR 0.96 (95%CI 0.93, 0.99), p = 0.005). Overestimated effort was rare (n = 37 (4%)) and associated with higher alveolar dead space (adjusted OR 1.05 (95%CI 1.01, 1.09), p = 0.007) and lower respiratory resistance (adjusted OR 0.32 (95%CI 0.13, 0.81), p = 0.017).

Conclusions: In patients with PARDS, P0.1 commonly underestimated high respiratory effort particularly with high airway resistance, high tidal volume, and high doses of opioids. Future studies are needed to investigate the impact of measures of respiratory effort, drive, and the presence of a mismatch phenotype on clinical outcome.

Trial registration: NCT03266016; August 23, 2017.

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当 P0.1 无法估计通气儿童的 ∆PES 时，基于呼吸驱动力的表型和识别风险因素的努力。

背景：需要在机械通气过程中监测呼吸强度和驱动力，以提供肺和膈肌保护。食管压力（∆PES）是衡量呼吸强度的黄金标准，但并非常规可用。呼吸前 100 毫秒的气道闭塞压（P0.1）是呼吸强度和驱动力的现成替代指标，但在儿童中与ΔPES 的相关性不大。我们试图找出通气儿童 P0.1 高估或低估 ∆PES 的风险因素：对参加小儿急性呼吸窘迫综合征（PARDS）肺和膈肌保护性通气随机对照试验（NCT03266016）的儿童和年轻成人的生理数据进行二次分析。∆每天测量ΔPES（ΔPES-REAL）、P0.1 和预测ΔPES（ΔPES-PRED = 5.91*P0.1）进行每日测量，根据呼吸努力和驱动力水平确定表型：一种是被动型（无自主呼吸），三种是 ∆PES-REAL 和 ∆PES-PRED 一致型（低、正常和高努力和驱动力），两种是 ∆PES-REAL 和 ∆PES-PRED 不匹配型（高度低估努力和高估努力）。与所有其他自主呼吸表型相比，我们使用逻辑回归模型确定了与每种不匹配表型（高水平低估用力或高估用力）相关的因素：我们对 953 个患者日（222 名患者）进行了分析。∆在 536 个（77%）活跃患者日中，ΔPES-REAL 和 ΔPES-PRED是一致的。高度低估的努力（n = 119 (12%)）与较高的气道阻力相关（调整后 OR 为 5.62 (95%CI 2.58, 12.26) 每对数单位的增加，p 结论：在 PARDS 患者中，P0.1 通常低估了高呼吸强度，尤其是在高气道阻力、高潮气量和大剂量阿片类药物的情况下。未来的研究需要调查呼吸强度、驱动力和错配表型的存在对临床结果的影响：NCT03266016；2017年8月23日。

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来源期刊

Critical Care 医学-危重病医学

CiteScore

20.60

自引率

3.30%

发文量

348

审稿时长

1.5 months

期刊介绍： Critical Care is an esteemed international medical journal that undergoes a rigorous peer-review process to maintain its high quality standards. Its primary objective is to enhance the healthcare services offered to critically ill patients. To achieve this, the journal focuses on gathering, exchanging, disseminating, and endorsing evidence-based information that is highly relevant to intensivists. By doing so, Critical Care seeks to provide a thorough and inclusive examination of the intensive care field.