体外膜氧合(ECMO)治疗难治性哮喘加重合并呼吸衰竭
2022/10/17
摘要
背景：哮喘急性加重合并呼吸衰竭(Asthma exacerbations with respiratory failure，AERF)与7-15%的医院死亡率相关。体外膜氧合(ECMO)已被用于抢救难治性AERF，但其与死亡率相关的对照研究尚未进行。
研究问题：与标准治疗相比，使用ECMO治疗难治性AERF是否与较低的死亡率相关？
方法：这是一项回顾性、流行病学、观察性队列研究，使用的是2010-2020年的全国性管理数据集，其中包括25%的美国住院患者。纳入标准为：患者因急性加重住进有ECMO能力的医院，并接受短效支气管扩张剂、全身皮质类固醇和有创呼吸机治疗。排除标准：年龄<18岁、无重症监护病房(ICU)、非哮喘、慢性肺部疾病、新冠肺炎或多次住院的患者。主要暴露是ECMO vs非ECMO。主要结果是住院死亡率。关键的次要结果是ICU住院时间、住院时间、有创机械通气时间和总住院费用。
结果：这项研究分析了13,714名AERF患者，其中127名使用ECMO，13,587名未使用ECMO。ECMO与死亡率降低相关，无论是协变量调整后(OR = 0.33;95% CI [0.17, 0.64]，p = 0.001)，倾向分数调整后(OR=0.36；95%CI[0.16，0.81]，p=0.01)还是使用倾向分数匹配模型后(OR=0.48；95%CI[0.24，0.98]，p=0.04)。敏感性分析显示，与ECMO相关的死亡率降低的OR值为0.34~0.61。与无ECMO相比，ECMO在所有三种模型中也与医院费用增加相关(p均<0.0001)，但与ICU住院时间、医院住院时间或有创通气时间降低无关。
结论：ECMO与较低的死亡率和较高的医院费用相关，提示经验证性临床试验后，它可能是难治性AERF的一种重要的抢救疗法。
Extracorporeal Membrane Oxygenation (ECMO) for Refractory Asthma Exacerbations with Respiratory Failure.
Zakrajsek JK, Min SJ, Ho PM.
Abstrast
Background: Asthma exacerbations with respiratory failure (AERF) are associated with hospital mortality of 7-15%. Extracorporeal membrane oxygenation (ECMO) has been used as a salvage therapy for refractory AERF, but controlled studies showing its association with mortality have not been performed.
Research question: Is treatment with ECMO associated with lower mortality in refractory AERF compared with standard care?
Methods: This is a retrospective, epidemiologic, observational cohort study using a national, administrative dataset from 2010-2020 that includes 25% of US hospitalizations. People were included if they were admitted to an ECMO-capable hospital with an AE, and were treated with short-acting bronchodilators, systemic corticosteroids and invasive ventilation. People were excluded for age <18 years, no intensive care unit (ICU) stay, non-asthma chronic lung disease, COVID-19 or multiple admissions. The main exposure was ECMO versus No ECMO. The primary outcome was hospital mortality. Key secondary outcomes were ICU length of stay (LOS), hospital LOS, time on invasive ventilation and total hospital costs.
Results: The study analyzed 13,714 AERF patients, including 127 ECMO and 13,587 No ECMO. ECMO was associated with reduced mortality in the covariate-adjusted (OR = 0.33; 95% CI [0.17, 0.64], p = 0.001), propensity score-adjusted (OR = 0.36; 95% CI [0.16, 0.81], p = 0.01) and propensity score matched models (OR = 0.48; 95% CI [0.24, 0.98], p = 0.04) versus No ECMO. Sensitivity analyses showed that mortality reduction related to ECMO ranged from OR = 0.34 to 0.61. ECMO was also associated with increased hospital costs in all three models (p <0.0001 for all) versus No ECMO, but not with decreased ICU LOS, hospital LOS, or time on invasive ventilation.
Conclusions: ECMO was associated with lower mortality and higher hospital costs, suggesting that it may be an important salvage therapy for refractory AERF following confirmatory clinical trials.
背景：哮喘急性加重合并呼吸衰竭(Asthma exacerbations with respiratory failure，AERF)与7-15%的医院死亡率相关。体外膜氧合(ECMO)已被用于抢救难治性AERF，但其与死亡率相关的对照研究尚未进行。
研究问题：与标准治疗相比，使用ECMO治疗难治性AERF是否与较低的死亡率相关？
方法：这是一项回顾性、流行病学、观察性队列研究，使用的是2010-2020年的全国性管理数据集，其中包括25%的美国住院患者。纳入标准为：患者因急性加重住进有ECMO能力的医院，并接受短效支气管扩张剂、全身皮质类固醇和有创呼吸机治疗。排除标准：年龄<18岁、无重症监护病房(ICU)、非哮喘、慢性肺部疾病、新冠肺炎或多次住院的患者。主要暴露是ECMO vs非ECMO。主要结果是住院死亡率。关键的次要结果是ICU住院时间、住院时间、有创机械通气时间和总住院费用。
结果：这项研究分析了13,714名AERF患者，其中127名使用ECMO，13,587名未使用ECMO。ECMO与死亡率降低相关，无论是协变量调整后(OR = 0.33;95% CI [0.17, 0.64]，p = 0.001)，倾向分数调整后(OR=0.36；95%CI[0.16，0.81]，p=0.01)还是使用倾向分数匹配模型后(OR=0.48；95%CI[0.24，0.98]，p=0.04)。敏感性分析显示，与ECMO相关的死亡率降低的OR值为0.34~0.61。与无ECMO相比，ECMO在所有三种模型中也与医院费用增加相关(p均<0.0001)，但与ICU住院时间、医院住院时间或有创通气时间降低无关。
结论：ECMO与较低的死亡率和较高的医院费用相关，提示经验证性临床试验后，它可能是难治性AERF的一种重要的抢救疗法。
(中日友好医院呼吸与危重症医学科 万静萱 摘译 林江涛 审校)
(Chest 2022 Sep 30; 10.1016/j.chest.2022.09.029. IF: 8.308)
(Chest 2022 Sep 30; 10.1016/j.chest.2022.09.029. IF: 8.308)
Extracorporeal Membrane Oxygenation (ECMO) for Refractory Asthma Exacerbations with Respiratory Failure.
Zakrajsek JK, Min SJ, Ho PM.
Abstrast
Background: Asthma exacerbations with respiratory failure (AERF) are associated with hospital mortality of 7-15%. Extracorporeal membrane oxygenation (ECMO) has been used as a salvage therapy for refractory AERF, but controlled studies showing its association with mortality have not been performed.
Research question: Is treatment with ECMO associated with lower mortality in refractory AERF compared with standard care?
Methods: This is a retrospective, epidemiologic, observational cohort study using a national, administrative dataset from 2010-2020 that includes 25% of US hospitalizations. People were included if they were admitted to an ECMO-capable hospital with an AE, and were treated with short-acting bronchodilators, systemic corticosteroids and invasive ventilation. People were excluded for age <18 years, no intensive care unit (ICU) stay, non-asthma chronic lung disease, COVID-19 or multiple admissions. The main exposure was ECMO versus No ECMO. The primary outcome was hospital mortality. Key secondary outcomes were ICU length of stay (LOS), hospital LOS, time on invasive ventilation and total hospital costs.
Results: The study analyzed 13,714 AERF patients, including 127 ECMO and 13,587 No ECMO. ECMO was associated with reduced mortality in the covariate-adjusted (OR = 0.33; 95% CI [0.17, 0.64], p = 0.001), propensity score-adjusted (OR = 0.36; 95% CI [0.16, 0.81], p = 0.01) and propensity score matched models (OR = 0.48; 95% CI [0.24, 0.98], p = 0.04) versus No ECMO. Sensitivity analyses showed that mortality reduction related to ECMO ranged from OR = 0.34 to 0.61. ECMO was also associated with increased hospital costs in all three models (p <0.0001 for all) versus No ECMO, but not with decreased ICU LOS, hospital LOS, or time on invasive ventilation.
Conclusions: ECMO was associated with lower mortality and higher hospital costs, suggesting that it may be an important salvage therapy for refractory AERF following confirmatory clinical trials.
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黏液栓在哮喘中的不同作用：吸烟的影响及其与气道炎症的关系
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呼吸道变应原的累积IgE水平作为预测以抗IgE为基础的重症哮喘治疗疗效的生物标志物
