CCM:免疫功能低下脓毒症患者从无创到有创机械通气延迟过渡对住院死亡率的影响

Abstract

Objective: To determine whether mortality differed between initial invasive mechanical ventilation (IMV) or noninvasive ventilation (NIV) followed by delayed IMV in immunocompromised patients with sepsis.

目的：确定在免疫功能低下的败血症患者中，初始侵入性机械通气（IMV）与随后延迟IMV的非侵入性通气（NIV）之间的死亡率是否存在差异。

Design: Retrospective analysis using the National Data Center for Medical Service claims data in China from 2017 to 2019.

设计：对中国2017至2019年国家医疗保障服务理赔数据进行回顾性分析。

Setting: A total of 3530 hospitals across China.

环境：中国共有3530家医院。

Patients: A total of 36,187 adult immunocompromised patients with sepsis requiring ventilation.

患者：共有36,187名需要通气的成年免疫功能低下的败血症患者。

Interventions: None.干预措施：无。

Measurements and main results: The primary outcome was hospital mortality. Patients were categorized into NIV initiation or IMV initiation groups based on first ventilation. NIV patients were further divided by time to IMV transition: no transition, immediate (≤ 1 d), early (2-3 d), delayed (4-7 d), or late (≥ 8 d). Mortality was compared between groups using weighted Cox models. Over the median 9-day follow-up, mortality was similar for initial NIV versus IMV (adjusted hazard ratio [HR] 1.006; 95% CI, 0.959-1.055). However, among NIV patients, a longer time to IMV transition is associated with stepwise increases in mortality, from immediate transition (HR 1.65) to late transition (HR 2.51), compared with initial IMV. This dose-response relationship persisted across subgroups and sensitivity analyses.

测量和主要结果：主要结果是医院死亡率。根据首次通气，患者被分为NIV开始组或IMV开始组。NIV患者进一步根据过渡到IMV的时间分为：无过渡、立即（≤1天）、早期（2-3天）、延迟（4-7天）或晚期（≥8天）。使用加权Cox模型比较各组间的死亡率。在平均9天的随访期间，初始NIV与IMV的死亡率相似（调整后的风险比[HR] 1.006；95% CI，0.959-1.055）。然而，在NIV患者中，过渡到IMV的时间越长，死亡率逐步增加，从立即过渡（HR 1.65）到晚期过渡（HR 2.51），与初始IMV相比。这种剂量-反应关系在各个亚组和敏感性分析中持续存在。

Conclusions: Prolonged NIV trial before delayed IMV transition is associated with higher mortality in immunocompromised sepsis patients ultimately intubated

结论：在免疫功能低下的败血症患者中，延迟过渡到IMV的NIV试验期延长与最终插管的患者的高死亡率相关。