俯卧位机械通气对急性肺损伤/急性呼吸窘迫综合征患者动脉氧合及血流动力学的影响研究

Effects of Prone Position Ventilation on Oxygenation and Hemodynamics in Patients with ALI /ARDS

目的探讨俯卧位机械通气(PPV)治疗对急性肺损伤(ALI)/急性呼吸窘迫综合征(ARDS)患者动脉氧合及血流动力学的影响。方法选择2009年7月—2011年6月云南省第一人民医院急诊科收治的肺内和/或肺外因素所致的ALI/ARDS患者67例,在一定肌松剂和镇静剂条件下进行PPV治疗。分别检测俯卧位(PP)前、PP 1h、PP 2 h、仰卧位(SP)1 h、SP 2 h时的血气分析指标〔包括酸碱度(pH)值、动脉血氧分压(PaO2)、二氧化碳分压(PaCO2)及氧合指数(PaO2/FiO2)〕及血流动力学指标〔包括心率(HR)、平均动脉压(MAP)、中心静脉压(CVP)、心排血量(CO)、每搏量(SV)及每搏量变异率(SVV)〕;观察患者皮肤黏膜损伤、血压下降、呕吐胃内容物等不良反应的发生情况。结果以PaO2升高>10 mm Hg(1 mm Hg=0.133 kPa)为改善患者氧合状态的有效指标,其中59例(88.1%)有效。不同时间点的PaO2、PaO2/FiO2比较,差异有统计学意义(P<0.05);PP 1 h、PP 2 h、SP 1 h、SP 2 h的PaO2、PaO2/FiO2均高于PP前(P<0.05)。不同时间点的pH值、PaCO2、HR、MAP、CVP、CO、SV、SVV比较,差异均无统计学意义(P>0.05)。PPV后29例(43.3%)ALI/ARDS患者出现受压部位皮肤潮红,但没有皮肤黏膜的损伤;11例(16.4%)出现皮下水肿加重;5例(7.5%)出现血压下降;6例(9.0%)出现呕吐胃内容物;其余患者均未观察到并发症的发生。67例患者中有8例(11.9%)对PPV治疗无反应。结论 PPV可改善ALL/ARDS患者动脉氧合情况,对血流动力学无明显影响,且无明显不良反应发生,近期临床疗效较好,为今后临床研究提供了参考依据。

Objective To explore effects of prone position ventilation （PPV） on oxygenation and hemodynamics in pa- tients with ALL/ARDS. Methods 67 patients with intrapulmonary factor - induced or extrapulmonary factor - induced ALL/ARDS who were admitted to department of emergency, the First People＇s Hospital of Yunnan Province from July 2009 to June 2011, were treated with prone position ventilation, muscle relaxants and sedatives. The arterial blood gas indexes （pH, PaO2, PaCO2, PaO2/FiO2 ） and bemodynamie indexes （HR, MAP, CVP, CO, SV and SVV） of patients were recorded before prone position （PP）, 1 h and 2 h after prone position （PP） , and 1 h and 2 h after supine position （SP） . The adverse reactions such as skin and mucous membrane injury, fall of blood pressure and vomiting the stomach contents were recorded. Results If PaO2 had risen by 〉 10 mm Hg （1 mm [4g =0. 133 kPa） , patients was regarded as oxygenation status improvement, 59 cases （88.1%） were effective. Significant difference was found among PaO2 and PaO2/FiO2 of different time points （P 〈 0. 05） . PaO2 and PaO2/FiO2 1 h and 2 h after PP, and 1 h and 2 h after SP were significantly higher than those before PP （P 〈 0.05 ） . No significant differ- ence were found among pH, PaOz, HR, MAP, CVP, CO, SV and SVV of different time points among ALI/ARDS patients （ P 〉 0. 05） . After PPV treatment, skin flushing was found in pressured zone of 29 （43.3%） ALI/ARDS patients, but skin and mucous membrane injury was not found. Cutaneous dropsy of 11 cases （16. 4% ） got worse, fall of blood pressure was found in 5 cases （7.5%）, vomiting the stomach contents was found in 6 cases （9. 0% ）, complication was not found in other patients. Among 67 cases, 8 cases （ 11.9% ） were unresponsive to PPV treatment. Conclusion PPV is a good therapeutic measure for patients with ALL/ARDS, which can improve the oxygenation of patients with little influence on hemodynamics, PPV has no significant adverse reactions, clinical efficacy is relatively good, the study can provide the references for future clinical research.