Sub-phenotyping of acute respiratory distress syndrome (ARDS) could be useful for evaluating the severity of ARDS or predicting its responsiveness to given therapeutic strategies, but no studies have yet investigated the heterogeneity of patients with severe ARDS requiring veno-venous extracorporeal membrane oxygenation (V-V ECMO). We conducted this retrospective multicenter observational study in adult patients with severe ARDS treated by V-V ECMO. We performed latent class analysis (LCA) for identifying sub-phenotypes of severe ARDS based on the radiological and clinical findings at the start of ECMO support. Multivariate Cox regression analysis was conducted to investigate the differences in mortality and association between the PEEP setting of ≥ 10 cmH2O and mortality by the sub-phenotypes. We identified three sub-phenotypes from analysis of the data of a total of 544 patients with severe ARDS treated by V-V ECMO, as follows: Dry type (n = 185; 34%); Wet type (n = 169; 31%); and Fibrotic type (n = 190; 35%). The 90-days in-hospital mortality risk was higher in the patients with the Fibrotic type than in those with the Dry type (adjusted hazard ratio [95% confidence interval] 1.75 [1.10–2.79], p = 0.019) or the Wet type (1.50 [1.02–2.23], p = 0.042). The PEEP setting of ≥ 10 cmH2O during the first 3 days of ECMO decreased the 90-days in-hospital mortality risk only in patients with the Wet type, and not in those with the Dry or Fibrotic type. A significant interaction effect was observed between the Wet type and the PEEP setting of ≥ 10 cmH2O in relation to the 90-day in-hospital mortality (pinteraction = 0.036). The three sub-phenotypes showed different mortality rates and different relationships between higher PEEP settings in the early phase of V-V ECMO and patient outcomes. Our data suggest that we may need to change our management approach to patients with severe ARDS during V-V ECMO according to their clinical sub-phenotype.

中文翻译：

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使用潜在类别分析鉴定需要 ECMO 的严重 ARDS 的新亚表型


急性呼吸窘迫综合征 （ARDS） 的亚表型可能有助于评估 ARDS 的严重程度或预测其对给定治疗策略的反应性，但尚未有研究调查需要静脉-静脉体外膜肺氧合 （V-V ECMO） 的严重 ARDS 患者的异质性。我们在接受 V-V ECMO 治疗的严重 ARDS 成年患者中进行了这项回顾性多中心观察研究。我们进行了潜在类别分析 （LCA），以根据 ECMO 支持开始时的放射学和临床发现确定严重 ARDS 的亚表型。进行多因素 Cox 回归分析，探讨 ≥ 10 cmH2O 的 PEEP 设置与亚表型死亡率的差异和相关性。我们从对总共 544 例接受 V-V ECMO 治疗的严重 ARDS 患者的数据分析中确定了三种亚表型，如下：干型 （n = 185;34%）;湿型 （n = 169; 31%）;和纤维化型 （n = 190; 35%）。纤维化型患者的 90 天院内死亡风险高于干型患者 （调整后的风险比 [95% 置信区间] 1.75 [1.10–2.79]，p = 0.019） 或湿型 （1.50 [1.02–2.23]，p = 0.042）。ECMO 前 3 天的 PEEP 设置为 ≥ 10 cmH2O 仅降低了湿型患者的 90 天院内死亡风险，而干性或纤维化型患者没有降低。观察到湿式和 ≥ 10 cmH2O 的 PEEP 设置与 90 天院内死亡率之间存在显着的交互效应 （pinteraction = 0.036）。 三种亚表型显示 V-V ECMO 早期较高的 PEEP 设置具有不同的死亡率和不同的关系与患者结局。我们的数据表明，我们可能需要根据 V-V ECMO 期间的临床亚表型改变对严重 ARDS 患者的管理方法。