PDF(Pubmed)
Abstract：
UNASSIGNED: Concern exists that noninvasive ventilation (NIV) may promote ventilation-induced lung injury(VILI) and worsen outcome in acute hypoxemic respiratory failure (AHRF). Different individual ventilatory variables have been proposed to predict clinical outcomes, with inconsistent results.Mechanical power (MP), a measure of the energy transfer rate from the ventilator to the respiratory system during mechanical ventilation, might provide solutions for this issue in the framework of predictive, preventive and personalized medicine (PPPM). We explored (1) the impact of ventilator-delivered MP normalized to well-aerated lung (MPWAL) on physio-anatomical and clinical responses to NIV in COVID-19-related AHRF and (2) the effect of prone position(PP) on MPWAL.
UNASSIGNED: We analyzed 216 noninvasively ventilated COVID-19 patients (108 patients receiving PP + NIV and 108 propensity score-matched patients receiving supine NIV) with moderate-to-severe(paO2/FiO2 ratio < 200) AHRF enrolled in the PRO-NIV controlled non-randomized study (ISRCTN23016116).Quantification of differentially aerated lung volumes by lung ultrasonography (LUS) was validated against CT scans. Respiratory parameters were hourly recorded, ABG were performed 1 h after each postural change. Time-weighed average values of ventilatory variables, including MPWAL, and gas exchange parameters (paO2/FiO2 ratio, dead space indices) were calculated for each ventilatory session. LUS and circulating biomarkers were assessed daily.
UNASSIGNED: Compared with supine position, PP was associated with a 34% MPWAL reduction, attributable largely to an absolute MP reduction and secondly to an enhanced lung reaeration.Patients receiving a high MPWAL during the 1st 24 h of NIV [MPWAL(day 1)] had higher 28-d NIV failure (HR = 4.33,95%CI:3.09 - 5.98) and death (HR = 5.17,95%CI: 3.01 - 7.35) risks than those receiving a low MPWAL(day 1).In Cox multivariate analyses, MPWAL(day 1) remained independently associated with 28-d NIV failure (HR = 1.68,95%CI:1.15-2.41) and death (HR = 1.69,95%CI:1.22-2.32).MPWAL(day 1) outperformed other power measures and ventilatory variables as predictor of 28-d NIV failure (AUROC = 0.89;95%CI:0.85-0.93) and death (AUROC = 0.89;95%CI:0.85-0.94).MPWAL(day 1) predicted also gas exchange, ultrasonographic and inflammatory biomarker responses, as markers of VILI, on linear multivariate analysis.
UNASSIGNED: In the framework of PPPM, early bedside MPWAL calculation may provide added value to predict response to NIV and guide subsequent therapeutic choices i.e. prone position adoption during NIV or upgrading to invasive ventilation, to reduce hazardous MPWAL delivery, prevent VILI progression and improve clinical outcomes in COVID-19-related AHRF.
UNASSIGNED: The online version contains supplementary material available at 10.1007/s13167-023-00325-5.
UNASSIGNED: We analyzed 216 noninvasively ventilated COVID-19 patients (108 patients receiving PP + NIV and 108 propensity score-matched patients receiving supine NIV) with moderate-to-severe(paO2/FiO2 ratio < 200) AHRF enrolled in the PRO-NIV controlled non-randomized study (ISRCTN23016116).Quantification of differentially aerated lung volumes by lung ultrasonography (LUS) was validated against CT scans. Respiratory parameters were hourly recorded, ABG were performed 1 h after each postural change. Time-weighed average values of ventilatory variables, including MPWAL, and gas exchange parameters (paO2/FiO2 ratio, dead space indices) were calculated for each ventilatory session. LUS and circulating biomarkers were assessed daily.
UNASSIGNED: Compared with supine position, PP was associated with a 34% MPWAL reduction, attributable largely to an absolute MP reduction and secondly to an enhanced lung reaeration.Patients receiving a high MPWAL during the 1st 24 h of NIV [MPWAL(day 1)] had higher 28-d NIV failure (HR = 4.33,95%CI:3.09 - 5.98) and death (HR = 5.17,95%CI: 3.01 - 7.35) risks than those receiving a low MPWAL(day 1).In Cox multivariate analyses, MPWAL(day 1) remained independently associated with 28-d NIV failure (HR = 1.68,95%CI:1.15-2.41) and death (HR = 1.69,95%CI:1.22-2.32).MPWAL(day 1) outperformed other power measures and ventilatory variables as predictor of 28-d NIV failure (AUROC = 0.89;95%CI:0.85-0.93) and death (AUROC = 0.89;95%CI:0.85-0.94).MPWAL(day 1) predicted also gas exchange, ultrasonographic and inflammatory biomarker responses, as markers of VILI, on linear multivariate analysis.
UNASSIGNED: In the framework of PPPM, early bedside MPWAL calculation may provide added value to predict response to NIV and guide subsequent therapeutic choices i.e. prone position adoption during NIV or upgrading to invasive ventilation, to reduce hazardous MPWAL delivery, prevent VILI progression and improve clinical outcomes in COVID-19-related AHRF.
UNASSIGNED: The online version contains supplementary material available at 10.1007/s13167-023-00325-5.
摘要：
■人们担心无创通气（NIV）可能会促进急性低氧性呼吸衰竭（AHRF）的通气诱导肺损伤（VILI）并恶化预后。已经提出了不同的个体通气变量来预测临床结果，结果不一致。机械动力(MP),在机械通气期间从呼吸机到呼吸系统的能量转移速率的量度，可能会在预测的框架内为这个问题提供解决方案，预防和个性化医疗(PPPM)。我们探讨了(1)在COVID-19相关的AHRF中，呼吸机输送的MP正常化为充气良好的肺(MPWAL)对NIV生理解剖和临床反应的影响，以及(2)俯卧位(PP)对MPWAL的影响。
■我们分析了PRO-NIV对照非随机研究(ISRCTN230116)中、重度(paO2/FiO2比值<200)AHRF的216例非侵入性通气COVID-19患者(108例接受PP+NIV和108例倾向评分匹配的仰卧NIV患者)。通过肺部超声检查（LUS）对不同充气量的定量与CT扫描进行了验证。每小时记录呼吸参数，每次姿势改变后1小时进行ABG。换气变量的时间加权平均值，包括MPWAL,和气体交换参数(PaO2/FiO2比，死腔指数)计算每个通气期。每天评估LUS和循环生物标志物。
■与仰卧位相比，PP与34%的MPWAL降低相关，主要归因于绝对MP减少，其次归因于肺复气增强。在NIV[MPWAL（第1天）]的第1个24小时内接受高MPWAL的患者比接受低MPWAL的患者具有更高的28dNIV失败（HR=4.33,95CI：3.09-5.98）和死亡（HR=5.17,95CI：3.01-7.35）风险。在Cox多变量分析中，MPWAL（第1天）与28dNIV失败（HR=1.68,95CI：1.15-2.41）和死亡（HR=1.69,95CI：1.22-2.32）独立相关。MPWAL（第1天）优于其他功率测量和通气变量，可预测28天NIV衰竭（AUROC=0.89；95CI：0.85-0.93）和死亡（AUROC=0.89；95CI：0.85-0.94）。MPWAL(第1天)还预测了气体交换，超声和炎症生物标志物反应，作为VILI的标记，关于线性多变量分析。
■在PPPM的框架中，早期的床旁MPWAL计算可以提供附加价值来预测对NIV的反应,并指导后续的治疗选择,即在NIV期间采用俯卧位或升级到有创通气,为了减少危险的MPWAL交付，预防COVID-19相关AHRF的VILI进展并改善临床结局。
■在线版本包含补充材料，可在10.1007/s13167-023-00325-5获得。
■我们分析了PRO-NIV对照非随机研究(ISRCTN230116)中、重度(paO2/FiO2比值<200)AHRF的216例非侵入性通气COVID-19患者(108例接受PP+NIV和108例倾向评分匹配的仰卧NIV患者)。通过肺部超声检查（LUS）对不同充气量的定量与CT扫描进行了验证。每小时记录呼吸参数，每次姿势改变后1小时进行ABG。换气变量的时间加权平均值，包括MPWAL,和气体交换参数(PaO2/FiO2比，死腔指数)计算每个通气期。每天评估LUS和循环生物标志物。
■与仰卧位相比，PP与34%的MPWAL降低相关，主要归因于绝对MP减少，其次归因于肺复气增强。在NIV[MPWAL（第1天）]的第1个24小时内接受高MPWAL的患者比接受低MPWAL的患者具有更高的28dNIV失败（HR=4.33,95CI：3.09-5.98）和死亡（HR=5.17,95CI：3.01-7.35）风险。在Cox多变量分析中，MPWAL（第1天）与28dNIV失败（HR=1.68,95CI：1.15-2.41）和死亡（HR=1.69,95CI：1.22-2.32）独立相关。MPWAL（第1天）优于其他功率测量和通气变量，可预测28天NIV衰竭（AUROC=0.89；95CI：0.85-0.93）和死亡（AUROC=0.89；95CI：0.85-0.94）。MPWAL(第1天)还预测了气体交换，超声和炎症生物标志物反应，作为VILI的标记，关于线性多变量分析。
■在PPPM的框架中，早期的床旁MPWAL计算可以提供附加价值来预测对NIV的反应,并指导后续的治疗选择,即在NIV期间采用俯卧位或升级到有创通气,为了减少危险的MPWAL交付，预防COVID-19相关AHRF的VILI进展并改善临床结局。
■在线版本包含补充材料，可在10.1007/s13167-023-00325-5获得。
