背景:由于最近的几项研究表明,烧伤后早期(≤7天)烧伤引起的ARDS的死亡率较低,这种情况下ARDS诊断的柏林标准可能存在争议.与这个问题有关,本研究调查了发病率,烧伤患者早期急性呼吸窘迫综合征(ARDS)的发病轨迹和危险因素,按照柏林标准,随着吸入性损伤的并发患病率和影响,呼吸机获得性肺炎(VAP)。
方法:在2.5年的时间里,纳入国家烧伤中心收治的烧伤总面积(TBSA)超过10%的烧伤患者.感兴趣的亚组包括通气支持超过48小时的患者。对该组进行ARDS评估,吸入性损伤,和VAP。
结果:在292名招生中,62持续烧伤>10%TBSA。其中,28人(45%)接受通气支持超过48小时,几乎所有,28人中有24人提前达到ARDS标准,受伤后7天内,第5天PaO2/FiO2(PF)比值最低点。早期ARDS组的死亡率低于10%,无论PF比率如何(平均TBSA%34,8%)。并发吸入性损伤和早期ARDS患者的PF比率显着降低(p<0.001),和更高的SOFA评分(p=0.004),但对死亡率没有影响。器官衰竭,由SOFA分数表示,提早(第3天)达到峰值,并在第一周下降,反映PF比率趋势(p<0.001)。
结论:本研究中烧伤患者早期ARDS的低死亡率挑战了早期ARDS诊断的柏林标准,其有效性依赖于较高的死亡率与PF比率恶化有关。该发现提出了替代机制,导致早期ARDS诊断,如吸入性损伤对早期PF比率和器官衰竭的显著影响,正如在这项研究中所看到的。早期器官衰竭与PF比率下降的并发,supports,正如预期的那样,创伤诱导的炎症/多器官衰竭机制有助于早期ARDS的假说。该研究强调了在烧伤护理轨迹早期区分吸入性损伤对早期ARDS的贡献和相关器官功能障碍的复杂性。ARDS诊断的柏林标准可能不适用于烧伤护理环境。其中低死亡率与原始柏林ARDS标准出版物中描述的明显不同,但在考虑本研究中实际不是非常广泛的烧伤大小/Baux评分时,这是预期的。
As several recent studies have shown low mortality rates in burn injury induced ARDS early (≤7 days) after the burn, the Berlin criteria for the ARDS diagnosis in this setting may be disputed. Related to this issue, the present study investigated the incidence, trajectory and risk factors of early Acute Respiratory Distress Syndrome (ARDS) and outcome in burn patients, as per the Berlin criteria, along with the concurrent prevalence and influence of inhalation injury, and ventilator-acquired pneumonia (VAP).
Over a 2.5-year period, burn patients with Total Burn Surface Area (TBSA) exceeding 10% admitted to a national burn center were included. The subgroup of interest comprised patients with more than 48 h of ventilatory support. This group was assessed for ARDS, inhalation injury, and VAP.
Out of 292 admissions, 62 sustained burns > 10% TBSA. Of these, 28 (45%) underwent ventilatory support for over 48 h, almost all, 24 out of 28, meeting the criteria for ARDS early, within 7 days post-injury and with a PaO2/FiO2 (PF) ratio nadir at day 5. The mortality rate for this early ARDS group was under 10%, regardless of PF ratios (mean TBSA% 34,8%). Patients with concurrent inhalation injury and early ARDS showed significantly lower PF ratios (p < 0.001), and higher SOFA scores (p = 0.004) but without impact on mortality. Organ failure, indicated by SOFA scores, peaked early (day 3) and declined in the first week, mirroring PF ratio trends (p < 0.001).
The low mortality associated with early ARDS in burn patients in this study challenges the Berlin criteria\'s for the early ARDS diagnosis, which for its validity relies on that higher mortality is linked to worsening PF ratios. The finding suggests alternative mechanisms, leading to the early ARDS diagnosis, such as the significant impact of inhalation injury on early PF ratios and organ failure, as seen in this study. The concurrence of early organ failure with declining PF ratios, supports, as expected, the hypothesis of trauma-induced inflammation/multi-organ failure mechanisms contributing to early ARDS. The study highlights the complexity in differentiating between the contributions of inhalation injury to early ARDS and the related organ dysfunction early in the burn care trajectory. The Berlin criteria for the ARDS diagnosis may not be fully applicable in the burn care setting, where the low mortality significantly deviates from that described in the original Berlin ARDS criteria publication but is as expected when considering the actual not very extensive burn injury sizes/Baux scores as in the present study.