三种肺复张方法在肺外源性急性呼吸窘迫综合征中的应用比较

Comparative study of three recruitment maneuvers in acute respiratory distress syndrome caused by extrapulmonary disease

目的 探讨三种不同的肺复张方法用于肺外源性急性呼吸窘迫综合征（ARDS）患者的效果和负影响.方法 肺外源性ARDS患者44例,按照交叉设计的方法在不同时段分别应用控制性肺膨胀（SI）、呼气末正压递增（IP）、压力控制（PCV）三种肺复张方法,记录肺复张前后患者心率、平均动脉压（MAP）、中心静脉压（CVP）、氧合指数、肺静态顺应性等指标的变化,并做统计学分析.结果 肺复张后患者短时间内氧合指数和肺静态顺应性都明显增加,IP法改善较SI、PCV两种方法更明显[肺复张后1h氧合指数：227±42比190±19、186±21;肺静态顺应性：（59.4±12.5）ml/cm H2O（1cm H2O=0.098 kPa）比（50.1±9.3）、（49.7±10.6）ml/cm H2O;P＜0.05],肺复张后2h三种方法比较差异无统计学意义（P＞0.05）.肺复张后患者短时间内均有心率增快,CVP上升,MAP下降,SI法变化幅度较IP、PCV两种方法小[肺复张后10 min心率：（94.0±10.3）次/min比（116.0±14.8）、（107.0±5.7）次/min;CVP：（13.7±3.1）cm H2O比（18.4±6.7）、（15.4±2.7）cm H2O;MAP：（87.0±12.1）mmHg（1mm Hg=0.133 kPa）比（73.0±4.8）、（81.0±6.6）mm Hg;P＜0.05],肺复张后20 min三种方法比较差异无统计学意义（P＞0.05）.结论 对于肺外源性ARDS行肺复张,IP法在肺顺应性和氧合改善方面效果最明显,SI法对血流动力学影响最小.

Abstract：Objective To evaluate the effects and side effects of three different recruitment maneuvers （RM） in acute respiratory distress syndrome （ARDS） caused by extrapulmonary disease.Methods Forty-four patients of extrapulmonary ARDS, according to crossover design methods, were undergone three RM in different periods, including sustained inflation （SI）, increase progressively positive end expiratory pressure （IP）, pressure control ventilation （PCV）. Heart rate （HR）, mean arterial blood pressure （MAP）, central venous pressure （CVP）, oxygenation index, lung compliance were recorded before and after RM, and were analyzed for statistical analysis. Results Oxygenation index and lung compliance were increased obviously in a short time after RM, improvement of IP method were better more obviously than the other two methods [1 h oxygenation index after RM：227 ± 42 vs 190 ± 19,186 ± 21 lung compliance：（59.4±12.5 ） ml/cm H2O（1 cm H2O = 0.098 kPa） vs （50.1 ± 9.3 ）, （49.7 ± 10.6） ml/cm H2O P〈 0.05], 2h after RM,there were no statistical difference among the three methods （P〉0.05）. After RM,HR and CVPwere increased, MAP was decreased in a short time, changes of SI method were smaller than the other two inethods [10 min HR after RM： （94.0±10.3 ） beats/min vs （116.0 ± 14.8 ）, （ 107.0 ± 5.7 ） beats/min CVP：（13.7±3.1 ）cm H2O vs （ 18.4 ± 6.7 ）, （ 15.4 ± 2.7 ）cm H2O MAP： （ 87.0 ± 12.1 ） mm Hg（ 1 mm Hg = 0.133 kPa） vs （73.0 ± 4.8）, （81.0 ± 6.6） mm Hg P〈 0.05）, 20 min after RM, there were no statistical difference among the three methods （P〉 0.05）. Conclusion When extrapulmonary ARDS undergo RM ,IP method is the most effective on increasing oxygenation index and lung compliance, SI method has the smallest side effect on hemodynamics.