小潮气量加肺复张对急性呼吸窘迫综合征的疗效观察

Curative effect of lung recruitment maneuvers combined with low tidal volume technique in acute respiratory distress syndrome

目的观察比较小潮气量加肺复张（RM）持续时间的选择对肺内／外源性急性呼吸窘迫综合征（ARDSp／ARDSexp）的影响。方法选择急性呼吸窘迫综合征（ARDS）患者26例，在机械通气基础上分别给予间歇高呼气末正压（PEEP）加小潮气量的RM，评价RM的不同持续时间对ARDSp（ARDSp组，10例）、ARDSexp（ARDSexp组，16例）的影响，比较二者间的差异。结果RM持续时间≥60s时平均动脉压（MAP）降低、HR加快，较RM前差异有统计学意义，RM停止后恢复正常。与RM前比较，气道平台压（Pplat）、呼吸系统顺应性（Crs）在RM实施时即明显增加（P〈0．05）；氧合指数（OI）在RM持续时间≥40s的三个时间段明显增加，SpO2在RM持续时间≥30s的四个时间段明显增加（P〈0．05）；在RM持续时间≥60s时，Pplat增加显著，而Crs、OI、SpO2较40-59s未见明显增加；对RM反应ARDSexp组优于ARDSp组，两组比较差异有统计学意义（P〈0．05）。ARDSp组出现气胸1例，皮下气肿3例；ARDSexp组出现皮下气肿2例，均发生在RM持续时间≥60s。结论间歇高PEEP加小潮气量的肺复张对ARDS有效，持续时间宜在40-59s，对肺外源性肺损伤比肺内源性肺损伤效果好。

Objective To study the effects of lung recruitment maneuvers （RM）with different duration combined with low tidal volume （TV）ventilation in acute respiratory distress syndrome （ARDS） with pulmonary and extra-pulmonary origin（ARDSp/ARDSexp）. Methods Twenty-six ARDS patients with ventilation were selected including 10 patients of ARDSp （ARDSp group） and 16 patients of ARDSexp （ARDSexp group）. All patients were given intermittent high-positive end expiratory pressure （PEEP） combined with low tidal volume RM in the base of usual ventilation. Effects of different duration of RM were evaluated and compared in the patients of ARDSp / ARDSexp. Results MAP decreased and HR increased when sustaining time of RM was above 60 seconds. Significant differences were showed compared with that before treatment. MAP and HR returned to normal after RM stopped.Compared with the state before RM, Pplat and Crs increased immediately after RM （P〈 0.05）. When RM lasted above 60 seconds, Pplat increased significantly compared with that when RM continue lasted 40-59 seconds.But Crs ,OI and SpO2 didn＇t increase obviously. Treatment effects of RM in patients of group ARDSexp were more obviously than those in patients of ARDSp group. There were 1 case of pneumothorax and 3 cases of pneumoderma in ARDSp group and 2 cases of pneumoderma in ARDSexp group when RM lasted above 60 seconds. Conclusions RM with intermittent high-PEEP on low TV is effective to ARDS and best duration is 40 - 59 seconds, The patients of ARDSexp, with pulmonary interstitial edema as the main pathology, respond better to RM than patients in ARDSp with pulmonary consolidation.