急性呼吸窘迫综合征患者保护性肺通气策略依从性现况调查  

Analysis of compliance with lung protective mechanical ventilation strategy in patients with acute respiratory distress syndrome

作　　者：刘有芳 詹庆元[2] 黄絮[2] 吴大玮 卢海宁 王导新[4] 邓旺[4] 孙同文[5] 邢丽华[6] 刘韶华[6] 王石磊[6] Liu Youfang;Zhan Qingyuan;Huang Xu;Wu Dawei;Lu Haining;Wang Daoxin;Deng Wang;Sun Tongwen;Xing Lihua;Liu Shaohua;Wang Shilei(China-Japan Friendship Clinical Medical College,Beijing University of Chinese Medicine,Beijing 100029,China;Center for Respiratory Diseases,China-Japan Friendship Hospital,Department of Pulmonary and Critical Care Medicine,National Clinical Research Center for Respiratory Diseases,National Center for Respiratory Medicine,Beijing 100029,China;Department of Critical Care Medicine,Qilu Hospital of Shandong University(Qingdao),Qingdao 266035,China;Department of Respiratory and Critical Care Medicine,the Second Affiliated Hospital of Chongqing,Medical University,Chongqing 400010,China;Intensive Care Unit,the First Affiliated Hospital of Zhengzhou University,Zhengzhou 450052,China;Department of Respiratory and Critical Care Medicine,the First Affiliated Hospital of Zhengzhou University,Zhengzhou 450052,China)

机构地区：[1]北京中医药大学中日临床医学院呼吸与危重症医学科,北京100029 [2]中日友好医院呼吸中心呼吸与危重症医学科国家呼吸医学中心国家呼吸疾病临床医学中心,北京100029 [3]山东大学齐鲁医院(青岛)重症医学科,青岛266035 [4]重庆医科大学附属第二医院呼吸与危重症医学科,重庆400010 [5]郑州大学第一附属医院综合ICU,郑州450052 [6]郑州大学第一附属医院呼吸与危重症医学科,郑州450052

出　　处：《中华结核和呼吸杂志》2024年第5期419-429,共11页Chinese Journal of Tuberculosis and Respiratory Diseases

摘　　要：目的评估急性呼吸窘迫综合征(ARDS)患者保护性肺通气策略依从性情况及其与预后关系。方法选取前瞻多中心队列研究(CHARDS)中进行有创机械通气的ARDS患者,收集患者的基本信息、机械通气数据和预后数据。依从性定义为潮气量≤7 ml/kg PBW或平台压≤30 cmH_(2)O或驱动压≤15 cmH_(2)O,潮气量纳入诊断ARDS后有创通气前7天数据,分为达标组(A组,100%达标)和非达标组(B组,50%~99%部分达标;C组,1%~49%部分达标;D组,完全不达标)。平台压、驱动压观察第一天数据。采用逐步回归方法,使用Logistics回归确定影响ICU存活的因素。结果共入组449例有创机械通气的ARDS患者,轻度、中度及重度患者分别为71例(15.8%)、198例(44.1%)和180例(40.1%)。前7天共监测到2880次潮气量数据,平均潮气量(6.89±1.93)ml/kg PBW,其中潮气量≤7 ml/kg PBW占53.2%。A、B、C、D组分别占29.8%(134/449)、24.5%(110/449)、23.6%(106/449)和22%(99/449)。轻度ARDS患者潮气量达标组18.3%(13/71)、非达标组81.7%(58/71);中度ARDS患者潮气量达标组25.8%(51/198)、非达标组74.2%(147/198);重度ARDS患者潮气量达标组38.9%(70/180)、非达标组61.1%(110/180),A组中重度ARDS患者达标率高于轻、中度ARDS患者(18.3%vs 25.8%vs 38.9%,χ^(2)=13.124,P=0.001)。221例患者记录平台压,95.9%(212/221)患者平台压≤30 cmH_(2)O;207例患者记录驱动压,77.8%(161/207)患者驱动压≤15 cmH_(2)O。前7天潮气量达标组ICU病死率低于非达标组(34.6%vs 51.3%,χ^(2)=10.464,P=0.001),达标组院内病死率低于非达标组(39.8%vs 57%,χ^(2)=11.016,P=0.001)。亚组分析显示中度和重度ARDS患者达标组ICU病死率和住院病死率均低于非达标组(均P<0.05),轻度ARDS患者达标与否的病死率差异无统计学意义(均P>0.05)。结论ARDS患者肺保护性机械通气策略整体依从性好,轻度ARDS患者依从性略低,平台压和驱动压依从性达标率高。潮气量完全依从性组较未依从组更能�Objective To assess the compliance with a lung protective ventilation strategy and to evaluate the relationship with prognosis in patients with acute respiratory distress syndrome(ARDS).Methods In the prospective multicenter cohort study(CHARDS),patients with ARDS undergoing invasive mechanical ventilation were enrolled to collect essential information,mechanical ventilation data,and prognostic data.Compliance was operationally defined as tidal volume≤7 ml/kg predicted body weight(PBW)or plateau pressure≤30 cmH_(2)O or driving pressure≤15 cmH_(2)O.Tidal volume data collected 7 days prior to ventilation after ARDS diagnosis were categorized into four groups:standard group(Group A,100%compliance),non-standard group(Group B,50%-99%compliance,Group C,1%-49%compliance,and Group D,totally non-compliant).Plateau pressure and drive pressure measurements were recorded on the first day.Stepwise regression,specifically Logistics regression,was used to identify the factors influencing ICU survival.Results A total of 449 ARDS patients with invasive mechanical ventilation were included;the proportion of mild,moderate,and severe patients was 71(15.8%),198(44.1%)and 180(40.1%),respectively.During the first 7 days,a total of 2880 tidal volume measurements were recorded with an average tidal volume of(6.89±1.93)ml/kg PBW.Of these measurements,53.2%were found to be≤7 ml/kg PBW.The rates of compliance with lung protective mechanical ventilation were 29.8%(134/449),24.5%(110/449),23.6%(106/449),and 22%(99/449)in groups A,B,C,and D,respectively.In the standard group,the tidal volume for mild ARDS patients was 18.3%(13/71),while it was 81.7%(58/71)in the non-standard group.Similarly,in patients with moderate ARDS,the tidal volume was 25.8%(51/198)in the standard group,while it was 74.2%(147/198)in the non-standard group.Finally,in patients with severe ARDS,the tidal volume was 38.9%(70/180)in the standard group,while it was 61.1%(110/180)in the non-standard group.Notably,the compliance rate was higher in patients with moderate

关 键 词：呼吸窘迫综合征 成人 肺保护性通气策略 潮气量 平台压 驱动压 

分 类 号：R563.8[医药卫生—呼吸系统]