패혈증 환자에게 급성호흡곤란증후군의 초기 예측인자로서 폐포사강환기비의 의의 (Alveolar Dead Space Ventilation Ratio as an Early Predictor of Acute Respiratory Distress Syndrome in Severe Sepsis and Septic Shock Patients)

서지정보

· 발행기관 : 대한응급의학회
· 수록지 정보 : 대한응급의학회지 / 19권 / 5호 / 481 ~ 488페이지
· 저자명 : 박상민, 홍윤식, 문성우, 최성혁, 김수진, 신중호, 신준현, 박종학, 이성우

초록

Purpose: Examine the clinical utility of the alveolar dead
space ventilation ratio (VdA/VT) as a predictor of acute respiratory
distress syndrome (ARDS) in severe sepsis and septic
shock patients.
Methods: A prospective observation study was done for
113 patients with severe sepsis and septic shock seen at
the emergency department of a university hospital from
January 2005 to June 2007. Therapies in the emergency
department included central venous access, antibiotics,
fluid resuscitation, mechanical ventilation, vasopressors
and inotropes as required. The major outcome assessed
was the development of ARDS within 3 days after admission.
Hemodynamic variables, arterial blood gas values,
serum lactate concentration, and estimated VdA/VT were
evaluated at presentation (0 hour) and at 4 hours. Briefly
the estimated VdA/VT was calculated by dividing the deference
of the arterial CO2 and end-tidal CO2 by the PaCO2
value. Data were presented as median±SD.
Results: ARDS developed in twenty-two patients (<24
hours: 17 persons, 24~48 hour: 4 persons, 48~72 hour: 1
person). Patients who developed ARDS had significantly
higher age, higher frequency of pneumonia, greater use of
mechanical ventilation and dubutamine during ED therapy,
and higher sepsis related organ failure assessment (SOFA)
scores. The in-hospital mortality of patients with ARDS was
significantly higher than that of patients without ARDS
(54.5% vs. 15.4%, p<0.001). Pneumonia, use of dobutamine
during ED therapy, and VdA/VT at 4 hours were independent
predictive factors for the development of ARDS.
The area under the receiving operating characteristic curve
for predicting ARDS was 0.891 (95% CI; 0.808-0.980) with
a value of VdA/VT at 4 hours. The cut off value of VdA/VT at 4
hours was 0.25 (sensitivity 81.8%, specificity 93.3%). At 4
hours, patients with VdA/VT equal to or greater than 0.25
under resuscitation showed a high rate of fluid and high inhospital
mortality when compared with patients with VdA/VT
<0.25 (CVP<10 cmH2O; 37.5% vs. 16.9%, p=0.047, mortality;
75.0% vs. 4.5%, p<0.001). In patients with VdA/VT equal
to or greater than 0.25 at 0 hour, patients without ARDS
showed significantly improvement of VdA/VT at 4 hours.
Conclusion: VdA/VT was found to be an independent predictive
variables for ARDS in the early in-hospital period.
Improvement of VdA/VT through early goal directed therapy
in emergency department may decrease the development
of ARDS in severe sepsis and septic shock patients.

영어초록

Purpose: Examine the clinical utility of the alveolar dead
space ventilation ratio (VdA/VT) as a predictor of acute respiratory
distress syndrome (ARDS) in severe sepsis and septic
shock patients.
Methods: A prospective observation study was done for
113 patients with severe sepsis and septic shock seen at
the emergency department of a university hospital from
January 2005 to June 2007. Therapies in the emergency
department included central venous access, antibiotics,
fluid resuscitation, mechanical ventilation, vasopressors
and inotropes as required. The major outcome assessed
was the development of ARDS within 3 days after admission.
Hemodynamic variables, arterial blood gas values,
serum lactate concentration, and estimated VdA/VT were
evaluated at presentation (0 hour) and at 4 hours. Briefly
the estimated VdA/VT was calculated by dividing the deference
of the arterial CO2 and end-tidal CO2 by the PaCO2
value. Data were presented as median±SD.
Results: ARDS developed in twenty-two patients (<24
hours: 17 persons, 24~48 hour: 4 persons, 48~72 hour: 1
person). Patients who developed ARDS had significantly
higher age, higher frequency of pneumonia, greater use of
mechanical ventilation and dubutamine during ED therapy,
and higher sepsis related organ failure assessment (SOFA)
scores. The in-hospital mortality of patients with ARDS was
significantly higher than that of patients without ARDS
(54.5% vs. 15.4%, p<0.001). Pneumonia, use of dobutamine
during ED therapy, and VdA/VT at 4 hours were independent
predictive factors for the development of ARDS.
The area under the receiving operating characteristic curve
for predicting ARDS was 0.891 (95% CI; 0.808-0.980) with
a value of VdA/VT at 4 hours. The cut off value of VdA/VT at 4
hours was 0.25 (sensitivity 81.8%, specificity 93.3%). At 4
hours, patients with VdA/VT equal to or greater than 0.25
under resuscitation showed a high rate of fluid and high inhospital
mortality when compared with patients with VdA/VT
<0.25 (CVP<10 cmH2O; 37.5% vs. 16.9%, p=0.047, mortality;
75.0% vs. 4.5%, p<0.001). In patients with VdA/VT equal
to or greater than 0.25 at 0 hour, patients without ARDS
showed significantly improvement of VdA/VT at 4 hours.
Conclusion: VdA/VT was found to be an independent predictive
variables for ARDS in the early in-hospital period.
Improvement of VdA/VT through early goal directed therapy
in emergency department may decrease the development
of ARDS in severe sepsis and septic shock patients.

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