論文No2429
Patterns of Use of Adjunctive Therapies in Patients With Early Moderate to Severe ARDS: Insights From the LUNG SAFE Study
Abhijit Duggal, Emanuele Rezoagli, Tài Pham, Bairbre A. McNicholas, Eddy Fan, Giacomo Bellani, Gordon Rubenfeld, Antonio M. Pesenti, John G. Laffey on behalf of the LUNG SAFE Investigators and the ESICM Trials Group
CHEST, June 2020, Volume 157, Issue 6, Pages 1497–1505
＜背景＞
補助療法はARDSの重要な役割を占める。
しかし、臨床実践における補助療法の実態はよくわかっていない。
＜目的＞
我々は中等症から重症のARDS(Pao2/Fio2 [P/F ratio] < 150)患者で
the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) studyに
登録された群で、補助療法の頻度、パターンを検討した。
＜方法＞
The LUNG SAFE studyは国際的な多施設前向きコホート研究で
重症呼吸不全を対象とし、50か国の459のICUで2014年に実施された。
このサブ研究の主要な目的は中等症から重症のARDS(P/F ratio <150)の最初の48時間において、
広く利用可能な（神経筋遮断薬、伏臥位）補助療法
vs 特異的装置(ECMO、吸入血管拡張、高頻度換気）の頻度を検討することである。
＜結果＞
中等症から重症のARDSで侵襲的換気を要する1146名の患者において、
811名(71%)はARDS発症後48時間で補助療法を受けていなかった。
補助療法を受けた335名(29%)のうち、252名(75%)は一つの療法を受け、
83名(25%)は二つ以上の補助療法を受けていた。
ARDSの死亡者のうち、67%は最初の48時間で補助療法を受けていなかった。
特異的装置(ECMO、吸入血管拡張、高頻度換気）を行ったうちの多く(67%)は
伏臥位や神経筋遮断薬をされていなかった。
補助療法を受けていた患者はよりARDSと認識され、より若く、より重症で、
肺炎の率が高く、換気がより困難で、高収入の国が多かった。
＜感想＞
中等症から重症のARDS患者のうち３割、死亡者の３割のみが、
ARDS発症の48時間以内に補助療法（神経筋遮断薬、伏臥位）を受けていたようです。
Background
Adjunctive strategies are an important part of the management of ARDS. However, their application in clinical practice remains inconsistent.
Research Question
We wished to determine the frequency and patterns of use of adjunctive strategies in patients with moderate to severe ARDS (Pao2/Fio2 [P/F ratio] < 150) enrolled into the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study.
Study Design and Methods
The LUNG SAFE study was an international, multicenter, prospective cohort study of patients with severe respiratory failure, conducted in 2014 in 459 ICUs from 50 countries. The primary objective of this substudy was to determine the frequency of use of widely available (neuromuscular blockade, prone position) adjuncts vs adjuncts requiring specialized equipment (extracorporeal membrane oxygenation, inhaled vasodilators, high-frequency ventilation) in patients in the first 48 h of moderate to severe ARDS (P/F ratio < 150).
Results
Of 1,146 patients on invasive ventilation with moderate to severe ARDS, 811 patients (71%) received no adjunct within 48 h of ARDS onset. Of 335 (29%) that received adjunctive strategies, 252 (75%) received a single strategy, and 83 (25%) receiving more than one adjunct. Of ARDS nonsurvivors, 67% did not receive any adjunctive strategy in the first 48 h. Most patients (67%) receiving specialized adjuncts did not receive prone positioning or neuromuscular blockade. Patients that received adjuncts were more likely to have their ARDS recognized, be younger and sicker, have pneumonia, be more difficult to ventilate, and be in a European high-income country than those that did not receive adjuncts.
Interpretation
Three in 10 patients with moderate to severe ARDS, and only one-third of nonsurvivors, received adjunctive strategies over the first 48 h of ARDS. A more consistent and evidence-driven approach to adjunct use may reduce costs and improve outcomes in patients with moderate to severe ARDS.