Emmanuel Futier, Audrey De Jong, Cédric Cirenei, Thomas Godet, Matthieu Jabaudon, Jean-Michel Constantin, Nicolas Grillot, Pierre Bouzat, Lois Henry, Dimitri Margetis, Gilles Lebuffe, Marc Garnier, Céline Lambert, Bruno Pereira, Samir Jaber
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引用次数: 0
Abstract
Purpose
Airway driving pressure has garnered considerable attention for lung-protective ventilation. We evaluated the clinical effectiveness of airway driving pressure as a target to individualize positive-end-expiratory pressure (PEEP) setting in mechanically ventilated patients at risk for postoperative respiratory failure.
Methods
We conducted a multicenter, pragmatic, assessor-masked, randomized trial among adult patients undergoing emergency abdominal surgery in 22 hospitals in France. Patients were assigned 1:1 to receive individually adjusted highest PEEP targeting a driving pressure < 13 cmH2O after an initial recruitment maneuver (intervention group) or to a fixed PEEP level of 5 cmH2O (control group). The primary outcome was a composite of postoperative respiratory failure (failure to wean from the ventilator or the composite of reintubation or curative non-invasive ventilation) or all-cause mortality at 30 days. Secondary outcomes included components of the composite primary outcome.
Results
The primary outcome occurred in 87 out of 338 (25.7%) intervention patients and in 69 out of 341 (20.2%) control patients (difference, 5.5%; 95% confidence interval [CI] − 0.8 to 11.8; relative risk, 1.27; 95%CI 0.96–1.68; p = 0.08). The difference was primarily due to an increased incidence of reintubation or need for curative non-invasive ventilation among intervention patients (difference, 7.1%; 95% CI 2.5–11.9; relative risk, 1.97; 95% CI 1.24–3.11; p = 0.004). Other secondary outcomes did not differ.
Conclusion
Among patients at risk for postoperative respiratory failure after emergency abdominal surgery, a strategy of individually adjusted highest PEEP in targeting driving pressure lower than 13 cmH2O did not reduce postoperative respiratory failure or death.
目的气道驱动压在肺保护性通气中的应用越来越受到重视。我们评估了气道驱动压力作为个体化呼气末正压（PEEP）设定的目标在有术后呼吸衰竭风险的机械通气患者中的临床有效性。方法：我们在法国22家医院接受急诊腹部手术的成年患者中进行了一项多中心、实用、评估器屏蔽的随机试验。患者按1:1分配，在初始招募操作后接受单独调整的最高PEEP（干预组），目标驱动压力为13 cmH2O，或固定PEEP水平为5 cmH2O（对照组）。主要结局是术后呼吸衰竭（未能脱离呼吸机或重新插管或治疗性无创通气的复合）或30天全因死亡率。次要结局包括复合主要结局的组成部分。结果干预组338例患者中有87例（25.7%）出现主要结局，对照组341例患者中有69例（20.2%）出现主要结局（差异为5.5%；95%可信区间[CI]−0.8 ~ 11.8；相对危险度为1.27;95%CI 0.96 ~ 1.68; p = 0.08）。差异主要是由于干预患者中再次插管或需要治疗性无创通气的发生率增加（差异，7.1%;95% CI 2.5-11.9；相对风险，1.97;95% CI 1.24-3.11; p = 0.004）。其他次要结果没有差异。结论在急诊腹部手术后存在术后呼吸衰竭风险的患者中，针对驱动压低于13 cmH2O的患者单独调整最高PEEP策略并不能减少术后呼吸衰竭或死亡。试验注册clinicaltrials .gov标识符：NCT03987789。
期刊介绍：
Intensive Care Medicine is the premier publication platform fostering the communication and exchange of cutting-edge research and ideas within the field of intensive care medicine on a comprehensive scale. Catering to professionals involved in intensive medical care, including intensivists, medical specialists, nurses, and other healthcare professionals, ICM stands as the official journal of The European Society of Intensive Care Medicine. ICM is dedicated to advancing the understanding and practice of intensive care medicine among professionals in Europe and beyond. The journal provides a robust platform for disseminating current research findings and innovative ideas in intensive care medicine. Content published in Intensive Care Medicine encompasses a wide range, including review articles, original research papers, letters, reviews, debates, and more.
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