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Trajectories of oxygenation index and PEEP levels associated with 28-day mortality in sepsis-associated ARDS: a
Background:
The prognostic value of dynamic PaO2/FiO2 trajectories and their interaction with positive end-expiratory pressure (PEEP) in sepsis-associated ARDS (SA-ARDS) remains unclear.
Methods:
This multicenter cohort study enrolled 732 SA-ARDS patients. K-means clustering identified phenotypes based on 168-hour PaO2/FiO2 trajectories. The primary outcome was 28-day mortality, analyzed using multivariable logistic regression, propensity score matching (PSM), inverse probability weighting (IPW), and generalized additive models.
Results:
Three phenotypes were identified: "Rebound Failure" (26.4%), "Gradual Recovery" (57.5%), and "Rapid Rebound" (16.1%). A significant mortality gradient was observed: 53.9%, 34.7%, and 13.6%, respectively (P < 0.001). Clusters 1 and 2 exhibited 3- to 8-fold higher 28-day mortality versus cluster 3, confirmed across multivariable regression, PSM, and IPW. Phenotype-specific PEEP effects emerged: early higher PEEP (≤ 10 cmH2O) benefited cluster 1 only within 24 hours, while sustained moderate PEEP (≤ 7.5 cmH2O) benefited clusters 2-3 across all intervals.
Conclusions:
Dynamic PaO2/FiO2 trajectories effectively stratify SA-ARDS patients into phenotypes with significant prognostic implications. Phenotype-stratified, time-dependent PEEP titration strategies warrant investigation.
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