比较针对有限驱动压力和低潮气量通气对 COVID-19 ARDS 机械通气成人死亡率的影响:探索性目标试验模拟。

IF 3.6 3区 医学 Q1 RESPIRATORY SYSTEM
Maged Tanios, Ting Ting Wu, Huang Mark Nguyen, Louisa Smith, Raja Mahidhara, John W Devlin
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引用次数: 0

摘要

背景:驱动压力(∆P)与有创机械通气(IMV)的结果之间可能存在关联。然而,对于接受 IMV 的急性呼吸窘迫综合征(ARDS)患者(包括 COVID-19 患者(COVID-19 相关急性呼吸窘迫综合征 (C-ARDS))),持续限制 ∆P 对其死亡率的影响尚未进行严格评估。在重症监护室研究中使用模拟目标试验仍处于起步阶段。为了给未来的大型 ARDS 目标试验提供信息,我们探索了使用目标试验模拟方法来分析一组接受 IMV 的 C-ARDS 成人患者的数据,以确定与单独使用 LTV 相比,除了传统的低潮气量通气(LTVV)(潮气量 5-7 cc/PBW+ 平台压(Pplat)≤30 cm H2O)外,维持每日 ∆p2O 是否会影响 28 天的死亡率:为了模拟目标试验,需要进行 24 小时以上 IMV 的 C-ARDS 成人患者被视为被分配到有限的 ∆P 或 LTVV。在调整呼吸机设置后,每天测量两次肺力学。为了评估每种肺保护通气(LPV)策略对 28 天死亡率的影响,我们拟合了一个稳定的逆概率加权边际结构模型,该模型调整了已知会影响保护策略使用/依从性或生存的基线和时变混杂因素:在纳入的 92 例患者中,27 例(29.3%)采用了有限的 ∆P 通气,23 例(25.0%)采用了 LTVV 策略,42 例(45.7%)未采用 LPV 策略。调整后的估计 28 天存活率为:有限 ∆P 组 47.0% (95% CI 23%, 76%)、LTVV 组 70.3% (95% CI 37.6%, 100%) 和无 LPV 策略组 37.6% (95% CI 20.8%, 58.0%):与LTVV相比,限制∆P可能不会为C-ARDS患者带来额外的生存获益。我们的研究结果有助于为未来目标试验模拟的开发提供参考,这些目标试验将重点评估LPV策略,包括降低ARDS成人患者的ΔP。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Comparing the impact of targeting limited driving pressure to low tidal volume ventilation on mortality in mechanically ventilated adults with COVID-19 ARDS: an exploratory target trial emulation.

Background: An association between driving pressure (∆P) and the outcomes of invasive mechanical ventilation (IMV) may exist. However, the effect of a sustained limitation of ∆P on mortality in patients with acute respiratory distress syndrome (ARDS), including patients with COVID-19 (COVID-19-related acute respiratory distress syndrome (C-ARDS)) undergoing IMV, has not been rigorously evaluated. The use of emulations of a target trial in intensive care unit research remains in its infancy. To inform future, large ARDS target trials, we explored using a target trial emulation approach to analyse data from a cohort of IMV adults with C-ARDS to determine whether maintaining daily ∆p<15 cm H2O (in addition to traditional low tidal volume ventilation (LTVV) (tidal volume 5-7 cc/PBW+plateau pressure (Pplat) ≤30 cm H2O), compared with LTVV alone, affects the 28-day mortality.

Methods: To emulate a target trial, adults with C-ARDS requiring >24 hours of IMV were considered to be assigned to limited ∆P or LTVV. Lung mechanics were measured twice daily after ventilator setting adjustments were made. To evaluate the effect of each lung-protective ventilation (LPV) strategy on the 28-day mortality, we fit a stabilised inverse probability weighted marginal structural model that adjusted for baseline and time-varying confounders known to affect protection strategy use/adherence or survival.

Results: Among the 92 patients included, 27 (29.3%) followed limited ∆P ventilation, 23 (25.0%) the LTVV strategy and 42 (45.7%) received no LPV strategy. The adjusted estimated 28-day survival was 47.0% (95% CI 23%, 76%) in the limited ∆P group, 70.3% in the LTVV group (95% CI 37.6%, 100%) and 37.6% (95% CI 20.8%, 58.0%) in the no LPV strategy group.

Interpretation: Limiting ∆P may not provide additional survival benefits for patients with C-ARDS over LTVV. Our results help inform the development of future target trial emulations focused on evaluating LPV strategies, including reduced ∆P, in adults with ARDS.

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来源期刊
BMJ Open Respiratory Research
BMJ Open Respiratory Research RESPIRATORY SYSTEM-
CiteScore
6.60
自引率
2.40%
发文量
95
审稿时长
12 weeks
期刊介绍: BMJ Open Respiratory Research is a peer-reviewed, open access journal publishing respiratory and critical care medicine. It is the sister journal to Thorax and co-owned by the British Thoracic Society and BMJ. The journal focuses on robustness of methodology and scientific rigour with less emphasis on novelty or perceived impact. BMJ Open Respiratory Research operates a rapid review process, with continuous publication online, ensuring timely, up-to-date research is available worldwide. The journal publishes review articles and all research study types: Basic science including laboratory based experiments and animal models, Pilot studies or proof of concept, Observational studies, Study protocols, Registries, Clinical trials from phase I to multicentre randomised clinical trials, Systematic reviews and meta-analyses.
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