连续性血液净化治疗肺外源性急性呼吸窘迫综合征的临床研究

Continuous Blood Purification in the Treatment of Patients with ARDS Caused by Extrapulmonary Causes

目的探讨连续性血液净化(CBP)早期治疗肺外源性ARDS中的临床价值。方法选取2009年8月至2010年12月间同一治疗组收治的急性生理学及慢性健康状况评价(APACHEⅡ)评分在15～20分之间,氧合指数(PaO2/FiO2)在100～200 mm Hg之间的肺外源性急性呼吸窘迫综合征(ARDS)患者35例,16例行连续性血液净化治疗,为CBP组;19例未予CBP治疗,为对照组。CBP组:采用连续性静静脉血液透析滤过(CVVHDF)模式,置换液流速1.5 L/h,透析液流速1.5 L/h,血流速度100～200 mL/min,治疗时间为72 h,统计学分析患者血液净化干预72 h NICO和PICCO相关指标变化及预后情况。结果 CBP组死亡率为6.3%,对照组死亡率为36.8%(P<0.05)。CBP组的肺毛细血管血流量(PCBF)、肺动态顺应性(Cdyn)、分钟CO2排出量(VCO2)、肺泡通气量(MValv)、平均气道压(Pm)、气道峰压(PIP)、气道阻力(Raw)、呼吸浅快指数(RSBI)、死腔通气/潮气量(Vd/Vt)、血管外肺水(EVLW)、肺血管通透性(PVPI)及PaO2/FiO2改善时间均明显早于对照组,效果也明显优于对照组,72 h的结果比较差异有统计学意义(P<0.05);平均动脉压(Apm)、心排指数(CI)及中心静脉压(CVP)未见明显变化(P>0.05)。结论在肺外源性ARDS治疗中,早期血液净化治疗可以减轻体内炎症反应,同时减少PCBF、EVLW,改善肺的顺应性,增加肺泡通气量,从而改善氧合指数,改善预后,且不会影响心功能和循环稳定,安全可靠。

Objective To investigate the value of continuous blood purification（CBP）in early treatment of patients with ARDSexp（ARDS caused by extrapulmonary causes）,especially in reducing inflammation mediators and extravascular lung water（EVLW）.Methods According the hospital admission sequence,the patients with APACHEⅡ scores from 15 to 20 and PaO2/FiO2 from 100 to 200 were recruited.The ARDSexp patients were divide into an intervention group treated with CBP（Mode：CVVHDF,rate of displacement liquid and dialysate：1.5 L/h,rate of blood：100-200 mL/h,and the time of CBP：72 hours）,and a control group without CBP treatment.The NICO and PICCO monitoring data and the survival rates were recorded and analyzed using the SPSS software.Results The mortality rate of the intervention group was lower than that of the control group（6.3% vs.36.8%,P=0.032）.In the 72 h monitoring dada of NICO and PICCO,the time of improving PCBF,Pm,Cdyn,VCO2,MValv,Pm,PIP,Raw,RSBI,Vd/Vt,and PaO2/FiO2 of the intervention group was severer than those in the control group,and the severity was also more than that of control group which was was significantly different at 72 h（P0.05）.In the PICCO data,the time of decreasing EVLW and PVPI was shorter than the control group,and the decreasing extent was more than the control group,with significant difference at 72h.But the changes of Apm,CI,and CVP were not significant（P0.05）.Conclusions In treatment of ARDSexp patients,CBP therapy can reduce the PCBC and EVLW,improve pulmonary compliance and MValv,and reduce the mortality rate,while doesn′t influence heart function and the stability of circulation.