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  • Title: [Analysis of compliance with lung protective mechanical ventilation strategy in patients with acute respiratory distress syndrome].
    Author: Liu YF, Zhan QY, Huang X, Wu DW, Lu HN, Wang DX, Deng W, Sun TW, Xing LH, Liu SH, Wang SL.
    Journal: Zhonghua Jie He He Hu Xi Za Zhi; 2024 May 12; 47(5):419-429. PubMed ID: 38706063.
    Abstract:
    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 cmH2O or driving pressure≤15 cmH2O. 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 and severe ARDS in group A compared to patients with mild and moderate ARDS (18.3% vs. 25.8% vs. 38.9%, χ2=13.124, P=0.001). Plateau pressure was recorded in 221 patients, 95.9% (212/221) patients with plateau pressure≤30 cmH2O, and driving pressure was recorded in 207 patients, 77.8% (161/207) patients with a driving pressure ≤15 cmH2O.During the first 7 days, the mortality rate in the intensive care unit (ICU) was lower in the tidal volume standard group compared to the non-standard group (34.6% vs. 51.3%, χ2=10.464, P=0.001). In addition, the in-hospital mortality rate was lower in the standard group compared to the non-standard group (39.8% vs. 57%, χ2=11.016, P=0.001).The results of the subgroup analysis showed that the mortality rates of moderate and severe ARDS patients in the standard group were significantly lower than those in the non-standard group, both in the ICU and in the hospital (all P<0.05). However, there was no statistically significant difference in mortality among mild ARDS patients (all P>0.05). Conclusions: There was high compliance with recommended lung protective mechanical ventilation strategies in ARDS patients, with slightly lower compliance in patients with mild ARDS, and high compliance rates for plateau and drive pressures. The tidal volume full compliance group had a lower mortality than the non-compliance group, and showed a similar trend in the moderate-to-severe ARDS subgroup, but there was no significant correlation between compliance and prognosis in patients with mild ARDS subgroup. 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 cmH2O或驱动压≤15 cmH2O，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2 880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%， χ2=13.124，P=0.001）。221例患者记录平台压，95.9%（212/221）患者平台压≤30 cmH2O；207例患者记录驱动压，77.8%（161/207）患者驱动压≤15 cmH2O。前7天潮气量达标组ICU病死率低于非达标组（34.6% vs 51.3%，χ2=10.464，P=0.001），达标组院内病死率低于非达标组（39.8% vs 57%，χ2=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改善ARDS患者病死率，且中重度亚组ARDS患者呈现相似的趋势，轻度ARDS患者依从性与否与预后无显著相关性。.
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