Objectives: 

Mechanical ventilation of patients with acute respiratory distress syndrome should balance lung and diaphragm protective principles, which may be difficult to achieve in routine clinical practice. Through a Phase I clinical trial, we sought to determine whether a computerized decision support–based protocol (real-time effort–driven ventilator management) is feasible to implement, results in improved acceptance for lung and diaphragm protective ventilation, and improves clinical outcomes over historical controls.

Design: 

Interventional nonblinded pilot study.

Setting: 

PICU.

Patients: 

Mechanically ventilated children with acute respiratory distress syndrome.

Interventions: 

A computerized decision support tool was tested which prioritized lung-protective management of peak inspiratory pressure–positive end-expiratory pressure, positive end-expiratory pressure/Fio₂, and ventilatory rate. Esophageal manometry was used to maintain patient effort in a physiologic range. Protocol acceptance was reported, and enrolled patients were matched 4:1 with respect to age, initial oxygenation index, and percentage of immune compromise to historical control patients for outcome analysis.

Measurements and Main Results: 

Thirty-two patients were included. Acceptance of protocol recommendations was over 75%. One-hundred twenty-eight matched historical controls were used for analysis. Compared with historical controls, patients treated with real-time effort–driven ventilator management received lower peak inspiratory pressure–positive end-expiratory pressure and tidal volume, and higher positive end-expiratory pressure when Fio₂ was greater than 0.60. Real-time effort–driven ventilator management was associated with 6 more ventilator-free days, shorter duration until the first spontaneous breathing trial and 3 fewer days on mechanical ventilation among survivors (all p ≤ 0.05) in comparison with historical controls, while maintaining no difference in the rate of reintubation.

Conclusions: 

A computerized decision support–based protocol prioritizing lung-protective ventilation balanced with reduction of controlled ventilation to maintain physiologic levels of patient effort can be implemented and may be associated with shorter duration of ventilation.

中文翻译：

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实时努力驱动的呼吸机管理：试点研究*

目标： 

急性呼吸窘迫综合征患者的机械通气应平衡肺和膈肌保护原则，这在常规临床实践中可能难以实现。通过 I 期临床试验，我们试图确定基于计算机决策支持的协议（实时努力驱动的呼吸机管理）是否可行，从而提高对肺和保护性隔膜通气的接受度，并改善临床结果历史控制。

设计： 

介入性非盲试验研究。

设置： 

重症监护病房。

患者： 

患有急性呼吸窘迫综合征的机械通气儿童。

干预： 

测试了一种计算机化决策支持工具，该工具优先考虑对峰值吸气压力 - 呼气末正压、呼气末正压/F io ₂和通气率的肺保护管理。食管测压法用于将患者的努力维持在生理范围内。报告了协议接受情况，入组患者在年龄、初始氧合指数和免疫损害百分比方面与历史对照患者进行了 4:1 匹配，以进行结果分析。

测量和主要结果： 

包括 32 名患者。协议建议的接受率超过 75%。128 个匹配的历史对照用于分析。与历史对照组相比，接受实时努力驱动呼吸机管理的患者的吸气峰压-呼气末正压和潮气量较低，而当 F io ₂大于 0.60 时，呼气末正压较高。实时努力驱动的呼吸机管理与幸存者的无呼吸机天数增加 6 天、直到第一次自主呼吸试验的持续时间更短以及机械通气天数减少 3 天相关（所有p≤ 0.05) 与历史对照相比，同时保持再插管率无差异。

结论： 

可以实施基于计算机决策支持的协议，优先考虑肺保护性通气与减少控制通气以保持患者努力的生理水平，并且可能与较短的通气持续时间相关。