Individualized Treatment Effects of Oxygen Targets in Mechanically Ventilated Critically Ill Adults

被引:34
作者
Buell, Kevin G. [1 ,2 ]
Spicer, Alexandra B. [3 ]
Casey, Jonathan D. [4 ]
Seitz, Kevin P. [4 ]
Qian, Edward T. [4 ]
Graham Linck, Emma J. [3 ]
Self, Wesley H. [5 ,6 ]
Rice, Todd W. [4 ,6 ]
Sinha, Pratik [7 ,8 ]
Young, Paul J. [9 ,10 ,11 ,12 ]
Semler, Matthew W. [4 ,6 ]
Churpek, Matthew M. [3 ]
机构
[1] Univ Chicago, Div Pulm & Crit Care, 5841 S Maryland Ave,MC6076, Chicago, IL 60637 USA
[2] Univ Illinois, Dept Med, Div Pulm & Crit Care, Chicago, IL USA
[3] Univ Wisconsin, Dept Med, Div Pulm & Crit Care Med, Madison, WI USA
[4] Vanderbilt Univ, Med Ctr, Dept Med, Div Allergy Pulm & Crit Care Med, Nashville, TN USA
[5] Vanderbilt Univ, Med Ctr, Dept Emergency Med, Nashville, TN USA
[6] Vanderbilt Inst Clin & Translat Res, Nashville, TN USA
[7] Washington Univ, Sch Med, Div Clin & Translat Res, St Louis, MO 63130 USA
[8] Washington Univ, Sch Med, Dept Anesthesia, Div Crit Care, St Louis, MO USA
[9] Wellington Hosp, Intens Care Unit, Wellington, New Zealand
[10] Med Res Inst New Zealand, Wellington, New Zealand
[11] Monash Univ, Australian & New Zealand Intens Care Res Ctr, Melbourne, Vic, Australia
[12] Univ Melbourne, Dept Crit Care, Melbourne, Vic, Australia
来源
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION | 2024年 / 331卷 / 14期
关键词
INTENSIVE-CARE; HETEROGENEITY; METAANALYSIS; THERAPY;
D O I
10.1001/jama.2024.2933
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
Importance Among critically ill adults, randomized trials have not found oxygenation targets to affect outcomes overall. Whether the effects of oxygenation targets differ based on an individual's characteristics is unknown. Objective To determine whether an individual's characteristics modify the effect of lower vs higher peripheral oxygenation-saturation (Spo2) targets on mortality. Design, Setting, and Participants A machine learning model to predict the effect of treatment with a lower vs higher Spo2 target on mortality for individual patients was derived in the Pragmatic Investigation of Optimal Oxygen Targets (PILOT) trial and externally validated in the Intensive Care Unit Randomized Trial Comparing Two Approaches to Oxygen Therapy (ICU-ROX) trial. Critically ill adults received invasive mechanical ventilation in an intensive care unit (ICU) in the United States between July 2018 and August 2021 for PILOT (n = 1682) and in 21 ICUs in Australia and New Zealand between September 2015 and May 2018 for ICU-ROX (n = 965). Exposures Randomization to a lower vs higher Spo2 target group. Main Outcome and Measure28-Day mortality. Results In the ICU-ROX validation cohort, the predicted effect of treatment with a lower vs higher Spo2 target for individual patients ranged from a 27.2% absolute reduction to a 34.4% absolute increase in 28-day mortality. For example, patients predicted to benefit from a lower Spo2 target had a higher prevalence of acute brain injury, whereas patients predicted to benefit from a higher Spo2 target had a higher prevalence of sepsis and abnormally elevated vital signs. Patients predicted to benefit from a lower Spo2 target experienced lower mortality when randomized to the lower Spo2 group, whereas patients predicted to benefit from a higher Spo2 target experienced lower mortality when randomized to the higher Spo2 group (likelihood ratio test for effect modification P = .02). The use of a Spo2 target predicted to be best for each patient, instead of the randomized Spo2 target, would have reduced the absolute overall mortality by 6.4% (95% CI, 1.9%-10.9%). Conclusion and relevance Oxygenation targets that are individualized using machine learning analyses of randomized trials may reduce mortality for critically ill adults. A prospective trial evaluating the use of individualized oxygenation targets is needed.
引用
收藏
页码:1195 / 1204
页数:10
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