控制性肺膨胀联合肺保护性通气策略在急性呼吸窘迫综合征的临床应用研究

Clinical Application of Sustained Inflation Combined with Lung Protective Ventilation Strategy in Patients with Acute Respiratory Distress Syndrome

目的观察控制性肺膨胀(SI)联合肺保护性通气策略对急性呼吸窘迫综合征(ARDS)患者的临床疗效。方法以25例ARDS病程早期的患者为研究对象,依据肺保护性通气策略确定基础通气模式,分别测定SI前、SI时,SI后10 min、1 h、2 h、3 h、4 h、5 h的肺气体交换、肺力学、血液动力学的变化。结果25例中,有2例因血压明显下降而退出,18例在实施SI后SaO2均有明显上升,有效率78,3%。SI时SaO2均有明显下降.但此后迅速上升,10 min～1h时达到最高值,疗效可维持4 h;SI能显著改善肺顺应性(Cdyn),SI后1 h时平台压(Pplat)即有明显下降.气道峰压(PIP),平均气道压(Pmean)在4h时下降明显;SI时CVP明显增加,但在SI结束后很快恢复到SI前水平。25例中未有气压伤的表现。结论SI联合肺保护性通气策略能有效复张塌陷的肺泡,降低气道压力,改善肺顺应性,增加氧合,对循环系统影响小,安全有效,但具有时效性,对于原发于肺部病变所致的ARDS合并血液动力学不稳定者应用SI要慎重。

Objective To evaluate the clinical therapeutic effects of sustained inflation（SI） combined with lung protective ventilation strategy（LPVS） in patients with acute respiratory distress syndrome（ARDS）. Methods To observe the influence of SI in eight time part（before SI, SI time, 10 min after SI, 1 h after SI, 2 h after SI, 3 h after SI, 4 h after SI, 5 h after SI,） on gas exchange, pulmonary mechanics, hemodynamics in 25 patients with ARDS, academic ventilation mode was confirmed by LPVS. Results Two patients exited because of the descent of blood pressure. Significant improvement in oxygenation occurred in 18 patients（78.3 % ）. The arterial blood oxygen saturation （SaO2） declined in the maneuver time but increased markedly after SI. SaO2 reached its maximum at 10 min to 1 h after SI and lasted for four hours. SI could improve pulmonary compliance markedly, plat airway pressure decreased significantly after 1 h of SI, peak airway pressure and mean airway pressure decreased significantly after 4 h of SI. Central venous pressure increased significantly during SI but reversed rapidly after the inflation was terminated. No barotraumas occurred in 25 patients. Conclusion SI combined LPVS could effectively re-expand pulmonary alveolus, decrease airway pressure, improve pulmonary compliance and oxygenation and had little influence on the circulatory system,but it had chronergy. Patients with ARDS caused by primarily pulmonary disease and instability hemodynamics should be treated with SI carefully.