集束化治疗中/重度急性呼吸窘迫综合征的多中心临床研究

A multicenter clinical study of bundle treatment for moderate or severe acute respiratory distress syndrome

目的：探讨中/重度急性呼吸窘迫综合征（ARDS）患者集束化治疗的疗效。方法采用与历史对照的前瞻性观察研究方法，纳入山东省泰安市中心医院重症医学科及河北省邯郸市中心医院重症医学科18～65岁、符合2011年ARDS柏林标准的肺内源性因素所致的中/重度ARDS患者共73例。以2012年9月至2014年5月为前瞻性观察期（集束化治疗组，33例）；以2010年1月至2012年8月为历史对照期（对照组，40例）。集束化治疗组在积极治疗原发病的基础上采用集束化治疗，包括：限制性液体管理、呼吸支持治疗、大剂量沐舒坦联合血必净注射液、呼吸机相关性肺炎（VAP）的预防、制定个体化镇静方案、重症患者应用连续性血液净化治疗；成立ARDS集束化治疗小组以保证各项措施顺利执行。比较两组患者治疗后5 d急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分和氧合指数，以及患者机械通气时间、重症加强治疗病房（ICU）住院时间、VAP发生率及28 d病死率。结果两组患者性别、年龄、病因构成、病情严重程度等基础特征比较差异均无统计学意义（均P＞0.05），有可比性。与对照组比较，集束化治疗组治疗后APACHEⅡ评分无明显变化（分：15.1±2.8比16.2±3.0，t＝1.618，P＝0.110），氧合指数明显增加〔mmHg（1 mmHg＝0.133 kPa）：135.4±34.5比117.1±34.2，t＝-2.273，P＝0.026〕，机械通气时间明显缩短（d：8.70±2.50比10.10±2.67，t＝2.308，P＝0.024），VAP发生率明显下降〔18.2%（6/33）比32.5%（13/40），χ2＝5.027，P＝0.025〕，28 d病死率明显降低〔24.2%（8/33）比37.5%（15/40），χ2＝4.372，P＝0.037〕，但在两组间ICU住院时间差异无统计学意义（d：10.40±1.94比11.30±2.34，t＝1.620，P＝0.110）。结论集束化治疗干预能缩短中/重度ARDS患者的机械通气时间，减少VAP发生率，改善患者预后。

ObjectiveTo investigate the efficacy of bundle treatment on patients with moderate or severe acute respiratory distress syndrome （ARDS）.Methods A multicenter prospective observational study comparing the result of historical treatment strategy and bundle treatment was conducted. According to the new Berlin standard of definition, 73 patients with moderate or severe ARDS due to pulmonary factors, age from 18 to 65 years, admitted to Department of Critical Care Medicine of Taian Central Hospital and Handan Central Hospital were enrolled. Thirty-three patients admitted during September 2012 to May 2014 （prospective observation period） were enrolled as the bundle treatment group. Forty patients with matched disease history admitted from January 2010 to August 2012 were enrolled as the control group. The patients in bundle treatment group received bundle treatment based on the treatment strategy of primary diseases. Bundle treatment included restrictive fluid management, respiratory support, high-dose ambroxol combined with Xuebijing injection, prevention of ventilation associated pneumonia （VAP）, individualized sedation plan, installation of continuous blood purification treatment for critical patients. A special team was organized to ensure the successful implementation of all bundle measures. The acute physiology and chronic health evaluationⅡ （APACHEⅡ） score, oxygenation index, duration of mechanical ventilation, the length of intensive care unit （ICU） stay, incidence of VAP, and 28-day mortality 5 days after treatment were compared between two groups.Results There were no significant differences in basic characteristics of patients between the two groups, including gender, age, etiology, severity, etc. （allP〉0.05） with comparability. Compared with the control group, there was no significant difference in APACHEⅡ score 5 days after treatment in bundle treatment group （15.1±2.8 vs. 16.2±3.0,t = 1.618,P = 0.110）. Compared with control group, oxygenation index in bundle treatment group was significantly improved [mmHg （1 mmHg = 0.133 kPa）： 135.4±34.5 vs. 117.1±34.2,t = -2.273,P = 0.026）, the duration of mechanical ventilation was obviously reduced （days： 8.70±2.50 vs. 10.10±2.67,t = 2.308,P = 0.024）, incidence of VAP was significantly lower [18.2% （6/33） vs. 32.5% （13/40）,χ2 = 5.027,P = 0.025], and 28-day mortality rate was obviously lowered [24.2% （8/33） vs. 37.5% （15/40）,χ2 = 4.372,P = 0.037], the length of ICU stay shown no statistical difference （days：10.40±1.94 vs. 11.30±2.34,t = 1.620,P = 0.110）.Conclusion Implementation of bundle treatment can significantly shorten the duration of mechanical ventilation, reduce the incidence of VAP, and improve the prognosis of patients.