We read with great interest the report of the LIVE study by Jean-Michel Constantin and colleagues, which assessed whether personalised mechanical ventilation according to lung morphology (focal vs non-focal) could improve acute respiratory distress syndrome (ARDS) survival outcomes compared with standard of care. The results for the primary outcome, 90-day mortality, were negative; however, misclassification of lung morphology occurred in 85 (21%) of 400 patients, and in the per-protocol analysis in which misclassified patients were excluded, mortality was significantly lower in the personalised ventilation group than in the control group. These findings support continued interest in the integration of lung morphology in ARDS management. However, the choice of imaging technique is a significant limitation of the study, and the methods used to investigate lung morphology need further consideration. Non-quantitative CT scanning was expected to be the reference technique, but most patients were assessed by chest x-ray, which has poor performance in ARDS. No patient was studied with lung ultrasound, although it was allowed per protocol. Lung ultrasound might be the ideal bedside imaging technique, because lung loss of aeration can be quantified on the basis of the visualised artifacts, with strong association with lung tissue density as measured by quantitative CT scan. To develop the skill of lung aeration assessment by ultrasound, at least 25 supervised examinations are required. Focal and non-focal ARDS can then be distinguished reliably at the bedside; moreover, the effects on lung aeration of procedures such as recruitment manoeuvres, positive end-expiratory pressure (PEEP) titration, or prone positioning can be monitored.

中文翻译：

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急性呼吸窘迫综合征中的个性化机械通气：正确的想法和错误的工具？

我们非常感兴趣地阅读了 Jean-Michel Constantin 及其同事的 LIVE 研究报告，该报告评估了是否根据肺形态（局部与与标准护理相比，非局部）可以改善急性呼吸窘迫综合征（ARDS）的生存结果。主要结局（90 天死亡率）的结果为阴性；然而，400 名患者中有 85 名 (21%) 发生了肺形态错误分类，在排除错误分类患者的符合方案分析中，个性化通气组的死亡率显着低于对照组。这些发现支持将肺形态学整合到 ARDS 管理中的持续兴趣。然而，成像技术的选择是该研究的一个重大限制，用于研究肺形态的方法需要进一步考虑。非定量 CT 扫描有望成为参考技术，但大多数患者通过胸部 X 光片进行评估，在 ARDS 中表现不佳。没有患者接受肺部超声检查，尽管按照方案允许。肺部超声可能是理想的床边成像技术，因为可以根据可视化伪影量化肺通气损失，并与定量 CT 扫描测量的肺组织密度密切相关。为了培养通过超声评估肺通气的技能，至少需要进行 25 次监督检查。然后可以在床边可靠地区分局灶性和非局灶性 ARDS；此外，可以监测诸如肺复张操作、呼气末正压 (PEEP) 滴定或俯卧位等程序对肺通气的影响。肺部超声可能是理想的床边成像技术，因为可以根据可视化伪影量化肺通气损失，并与定量 CT 扫描测量的肺组织密度密切相关。为了培养通过超声评估肺通气的技能，至少需要进行 25 次监督检查。然后可以在床边可靠地区分局灶性和非局灶性 ARDS；此外，可以监测诸如肺复张操作、呼气末正压 (PEEP) 滴定或俯卧位等程序对肺通气的影响。肺部超声可能是理想的床边成像技术，因为可以根据可视化伪影量化肺通气损失，并与定量 CT 扫描测量的肺组织密度密切相关。为了培养通过超声评估肺通气的技能，至少需要进行 25 次监督检查。然后可以在床边可靠地区分局灶性和非局灶性 ARDS；此外，可以监测诸如肺复张操作、呼气末正压 (PEEP) 滴定或俯卧位等程序对肺通气的影响。为了培养通过超声评估肺通气的技能，至少需要进行 25 次监督检查。然后可以在床边可靠地区分局灶性和非局灶性 ARDS；此外，可以监测诸如肺复张操作、呼气末正压 (PEEP) 滴定或俯卧位等程序对肺通气的影响。为了培养通过超声评估肺通气的技能，至少需要进行 25 次监督检查。然后可以在床边可靠地区分局灶性和非局灶性 ARDS；此外，可以监测诸如肺复张操作、呼气末正压 (PEEP) 滴定或俯卧位等程序对肺通气的影响。