高呼气末正压在神经源性肺水肿机械通气中的作用

Effect of high positive end-expiratory pressure for mechanical ventilation in the treatment of neurological pulmonary edema

目的 探讨高呼气末正压（PEEP）在神经源性肺水肿（NPE）机械通气中的作用,寻找改善预后的最佳机械通气策略.方法 采用前瞻性研究方法,选择2010年1月至2013年8月广西中医药大学第一附属医院重症医学科120例NPE患者,按随机数字表法分为两组,每组60例.两组患者均针对原发病给予对症治疗和经鼻气管插管机械通气,普通PEEP组PEEP为3～ 10 cmH2O（1 cmH2O=0.098 kPa）,高PEEP组PEEP为11～30 cmH2O,其余机械通气参数相同.对比两组治疗前及治疗后7d各临床指标及28 d病死率.结果 高PEEP组28 d病死率明显低于普通PEEP组[25.0％（15/60）比65.0％（39/60）,Х^2=6.465,P=0.011].两组治疗后各指标均明显改善,高PEEP组改善程度较普通PEEP组更明显,其中两组治疗后体温（℃：37.4±0.5比38.5±0.6）、呼吸频率（次/min：18.3±3.1比23.3±3.5）、心率（次/min 94.7±8.5比113.5±8.0）、白细胞计数[WBC（×10^9/L）：12.5±2.1比17.1±1.7]、急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分（分：15.6±3.2比19.8±3.7）、格拉斯哥昏迷评分[GCS（分）：12.5±2.1比8.5±2.9]、胃肠功能评分（分：3.9±3.0比3.6±2.4）、氧合指数[PaO2/FiO2（mmHg,1 mmHg=0.133 kPa）：196.5±45.1比134.1±22.3]、血肌酐[SCr（μmol/L）：86.5±35.6比98.5±37.7]、总胆红素[TBil （μmol/L）：39.7±23.5比41.5±16.2]、C-反应蛋白[CRP（mmol/L）：53.7±21.4比108.4±26.3]、凝血酶原时间[PT（s） 15.0±2.1比20.4±2.2]、活化部分凝血活酶时间[APTT（s） 37.3±4.9比56.7±13.6]、国际标准化比值（INR 2.52±0.65比4.01±0.77）、血管外肺水指数[EVLWI（mL/kg）：7.53±1.21比15.85±3.41]、肺血管通透性指数（PVPI：6.07±0.89比9.47±1.26）、平均动脉压[MAP （mmHg）：87.3±10.9比98.7±13.6]、心排血量[CO（L/min） 7.15±1.42比5.65±1.82]、体循环阻力指数[SVRI （KP）：112.4±9.5比136.5±11.9]、动脉血乳酸（mmol/L 2.53±1.23比5.81±2.17）比较差异均有统计学意义（P＜ 0.05或P＜0.01）.结论 在NPE患者机械通气中采用高PEEP通气可以改善患者氧合,降低28 d病死率.

Objective To explore the effect of high positive end-expiratory pressure （PEEP） for the treatment of neurological pulmonary edema （NPE） in patients undergoing mechanical ventilation,and to look for the best mechanical ventilation strategy to improve the prognosis.Methods A prospective study was conducted,and 120 patients with NEP admitted to Department of Critical Care Medicine of the First Affiliated Hospital of Guangxi Traditional Chinese Medical University from January 2010 to August 2013 were enrolled and divided into two groups according to random number table （n=60 in each group）.The patients in two groups were given empiric treatment for the disease,and they underwent mechanical ventilation.In the normal PEEP group PEEP was 3-10 cmH2O （1 cmH2O =0.098 kPa）,and in the high PEEP group PEEP was 11-30 cmH2O,and all the rest parameters were the same.Clinical indices before and 7 days after treatment,and 28-day morality rate were compared between two groups.Results The 28-day morality rate in high PEEP group was obviously lower than that in the normal PEEP group [25.0% （15/60） vs.65.0% （39/60）,Х^2=6.465,P=0.011].The clinical signs in both groups were improved after treatment.Compared with the normal PEEP group,the clinical indices in high PEEP group were more significantly improved.There were significant differences in body temperature （℃ 37.4 ± 0.5 vs.38.5 ± 0.6）,respiratory rate （times/min 18.3 ± 3.1 vs.23.3 ±3.5）,heart rate （beats/min 94.7 ±8.5 vs.113.5 ±8.0）,white blood cell count [WBC （× 10^9/L） 12.5 ±2.1 vs.17.1 ± 1.7],acute physiology and chronic health evaluation Ⅱ （APACHE Ⅱ） score （15.6 ± 3.2 vs.19.8 ± 3.7）,Glasgow coma score （GCS 12.5 ± 2.1 vs.8.5 ± 2.9）,gastrointestinal dysfunction score （3.9 ± 3.0 vs.3.6 ± 2.4）,oxygenation index [PaO2/FiO2 （mmHg,1 mmHg=0.133 kPa） 196.5 ± 45.1 vs.134.1 ± 22.3],serum creatinine [SCr （μmol/L） 86.5 ± 35.6 vs.98.5 ± 37.7],total bilirubin [TBil （μmol/L） 39.7 ± 23.5 vs.41.5 ± 16.2],C-reacting protein [CRP （mmol/L） 53.7 ± 21.4 vs.108.4 ± 26.3],prothrombin time [PT （s） 15.0 ± 2.1 vs.20.4 ± 2.2],activated partial thromboplastin time [APTT （s）：37.3 ±4.9 vs.56.7 ± 13.6],international normalized ratio （INR 2.52 ±0.64 vs.4.01 ±0.77）,extra vascular lung water index [EVLWI （mL/kg） 7.53 ± 1.21 vs.15.85 ±3.41],pulmonary vascular permeability index （PVPI 6.07 ± 0.89 vs.9.47 ± 1.26）,mean arterial pressure [MAP （mmHg） 87.3 ± 10.9 vs.98.7 ± 13.6],cardiac output [CO （L/min） 7.15 ± 1.42 vs.5.65 ± 1.82],systemic vascular resistance index [SVRI （KP） 112.4 ± 9.5 vs.136.5 ± 11.9],and blood lactate （mmol/L：2.53 ± 1.23 vs.5.81 ± 2.17） between high PEEP group and normal PEEP group （P〈0.05 or P〈0.01）.Conclusion Prognosis can be improved in NPE patients with the use of high PEEP in mechanical ventilation.