Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome - A randomized controlled trial

被引:1277
作者
Ranieri, VM
Suter, PM
Tortorella, C
De Tullio, R
Dayer, JM
Brienza, A
Bruno, F
Slutsky, AS
机构
[1] Univ Toronto, Mt Sinai Hosp, Samuel Lunenfeld Res Inst, Dept Med, Toronto, ON M5G 1X5, Canada
[2] Univ Bari, Osped Policlin, Ist Anestesiol & Rianimaz, Bari, Italy
[3] Univ Bari, Osped Policlin, Serv Pneumol, Bari, Italy
[4] Univ Bari, Osped Policlin, Dipartimento Med Interna, Bari, Italy
[5] Univ Geneva, Hop Cantonal Univ Geneva, Div Surg Intens Care, Geneva, Switzerland
[6] Univ Geneva, Hop Cantonal Univ Geneva, Div Immunol & Allergy, Geneva, Switzerland
来源
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION | 1999年 / 282卷 / 01期
关键词
D O I
10.1001/jama.282.1.54
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
Context Studies have shown that an inflammatory response may be elicited by mechanical ventilation used for recruitment or derecruitment of collapsed lung units or to overdistend alveolar regions, and that a lung-protective strategy may reduce this response. Objective To test the hypothesis that mechanical ventilation induces a pulmonary and systemic cytokine response that can be minimized by limiting recruitment or derecruitment and overdistention. Design and Setting Randomized controlled trial in the intensive care units of 2 European hospitals from November 1995 to February 1998, with a 28-day follow-up. Patients Forty-four patients (mean [SD] age, 50 [18] years) with acute respiratory distress syndrome were enrolled, 7 of whom were withdrawn due to adverse events. Interventions After admission, volume-pressure curves were measured and bronchoalveolar lavage and blood samples were obtained. Patients were randomized to either the control group (n = 19). tidal volume to obtain normal values of arterial carbon dioxide tension (35-40 mm Hg) and positive end-expiratory pressure (PEEP) producing the greatest improvement in arterial oxygen saturation without worsening hemodynamics; or the lung-protective strategy group (n = 18), tidal volume and PEEP based on the volume-pressure curve. Measurements were repeated 24 to 30 and 36 to 40 hours after randomization. Main Outcome Measures Pulmonary and systemic concentrations of inflammatory mediators approximately 36 hours after randomization. Results Physiological characteristics and cytokine concentrations were similar in both groups at randomization. There were significant differences (mean [SD]) between the control and lung-protective strategy groups in tidal volume (11.1 [1.3] vs 7.6 [1.1] mL/kg), end-inspiratory plateau pressures (31.0 [4.5] vs 24.6 [2.4] cm H2O), and PEEP (6.5 [1.7] vs 14.8 [2.7] cm H2O) (P<.001), Patients in the control group had an in crease in bronchoalveolar lavage concentrations of interleukin (IL) 1 beta, IL-6, and IL-1 receptor agonist and in both bronchoalveolar lavage and plasma concentrations of tumor necrosis factor (TNF) alpha, IL-6, and TNF-alpha receptors over 36 hours (P<.05 for all). Patients in the lung-protective strategy group had a reduction in bronchoalveolar lavage concentrations of polymorphonuclear cells, TNF-alpha, IL-1 beta, soluble TNF-alpha receptor 55, and IL-8, and in plasma and bronchoalveolar lavage concentrations of IL-6, soluble TNF-alpha receptor 75, and IL-1 receptor antagonist (P<.05). The concentration of the inflammatory mediators 36 hours after randomization was significantly lower in the lung-protective strategy group than in the control group (P<.05). Conclusions Mechanical ventilation can induce a cytokine response that may be attenuated by a strategy to minimize overdistention and recruitment/derecruitment of the lung, Whether these physiological improvements are associated with improvements in clinical end points should be determined in future studies.
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页码:54 / 61
页数:8
相关论文
共 42 条
  • [1] Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome
    Amato, MBP
    Barbas, CSV
    Medeiros, DM
    Magaldi, RB
    Schettino, GDP
    Lorenzi, G
    Kairalla, RA
    Deheinzelin, D
    Munoz, C
    Oliveira, R
    Takagaki, TY
    Carvalho, CRR
    [J]. NEW ENGLAND JOURNAL OF MEDICINE, 1998, 338 (06) : 347 - 354
  • [2] The effects of ibuprofen on the physiology and survival of patients with sepsis
    Bernard, GR
    Wheeler, AP
    Russell, JA
    Schein, R
    Summer, WR
    Steinberg, KP
    Fulkerson, WJ
    Wright, PE
    Christman, BW
    Dupont, WD
    Higgins, SB
    Swindell, BB
    [J]. NEW ENGLAND JOURNAL OF MEDICINE, 1997, 336 (13) : 912 - 918
  • [3] THE AMERICAN-EUROPEAN CONSENSUS CONFERENCE ON ARDS - DEFINITIONS, MECHANISMS, RELEVANT OUTCOMES, AND CLINICAL-TRIAL COORDINATION
    BERNARD, GR
    ARTIGAS, A
    BRIGHAM, KL
    CARLET, J
    FALKE, K
    HUDSON, L
    LAMY, M
    LEGALL, JR
    MORRIS, A
    SPRAGG, R
    COCHIN, B
    LANKEN, PN
    LEEPER, KV
    MARINI, J
    MURRAY, JF
    OPPENHEIMER, L
    PESENTI, A
    REID, L
    RINALDO, J
    VILLAR, J
    VANASBECK, BS
    DHAINAUT, JF
    MANCEBO, J
    MATTHAY, M
    MEYRICK, B
    PAYEN, D
    PERRET, C
    FOWLER, AA
    SCHALLER, MD
    HUDSON, LD
    HYERS, T
    KNAUS, W
    MATTHAY, R
    PINSKY, M
    BONE, RC
    BOSKEN, C
    JOHANSON, WG
    LEWANDOWSKI, K
    REPINE, J
    RODRIGUEZROISIN, R
    ROUSSOS, C
    ANTONELLI, MA
    BELOUCIF, S
    BIHARI, D
    BURCHARDI, H
    LEMAIRE, F
    MONTRAVERS, P
    PETTY, TL
    ROBOTHAM, J
    ZAPOL, W
    [J]. AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE, 1994, 149 (03) : 818 - 824
  • [4] Tidal volume reduction for prevention of ventilator-induced lung injury in acute respiratory distress syndrome
    Brochard, L
    Roudot-Thoraval, F
    Roupie, E
    Delclaux, C
    Chastre, J
    Fernandez-Mondéjar, E
    Clémenti, E
    Mancebo, J
    Factor, P
    Matamis, D
    Ranieri, M
    Blanch, L
    Rodi, G
    Mentec, H
    Dreyfuss, D
    Ferrer, M
    Brun-Buisson, C
    Tobin, M
    Lemaire, F
    [J]. AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE, 1998, 158 (06) : 1831 - 1838
  • [5] CHIUMELLO D, 1998, AM J RESP CRIT CARE, V157, pA45
  • [6] INTERLEUKIN-8 AND DEVELOPMENT OF ADULT RESPIRATORY-DISTRESS SYNDROME IN AT-RISK PATIENT GROUPS
    DONNELLY, SC
    STRIETER, RM
    KUNKEL, SL
    WALZ, A
    ROBERTSON, CR
    CARTER, DC
    GRANT, IS
    POLLOK, AJ
    HASLETT, C
    [J]. LANCET, 1993, 341 (8846) : 643 - 647
  • [7] The regional production of cytokines and lactate in sepsis-related multiple organ failure
    Douzinas, EE
    Tsidemiadou, PD
    Pitaridis, MT
    Andrianakis, I
    BobotaChloraki, A
    Katsouyanni, K
    Sfyras, D
    Malagari, K
    Roussos, C
    [J]. AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE, 1997, 155 (01) : 53 - 59
  • [8] ROLE OF TIDAL VOLUME, FRC, AND END-INSPIRATORY VOLUME IN THE DEVELOPMENT OF PULMONARY-EDEMA FOLLOWING MECHANICAL VENTILATION
    DREYFUSS, D
    SAUMON, G
    [J]. AMERICAN REVIEW OF RESPIRATORY DISEASE, 1993, 148 (05): : 1194 - 1203
  • [9] REGIONAL EFFECTS AND MECHANISM OF POSITIVE END-EXPIRATORY PRESSURE IN EARLY ADULT RESPIRATORY-DISTRESS SYNDROME
    GATTINONI, L
    DANDREA, L
    PELOSI, P
    VITALE, G
    PESENTI, A
    FUMAGALLI, R
    [J]. JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 1993, 269 (16): : 2122 - 2127
  • [10] Inflammatory cytokines in patients with persistence of the acute respiratory distress syndrome
    Goodman, RB
    Strieter, RM
    Martin, DP
    Steinberg, KP
    Milberg, JA
    Maunder, RJ
    Kunkel, SL
    Walz, A
    Hudson, LD
    Martin, TR
    [J]. AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE, 1996, 154 (03) : 602 - 611