气道压力释放通气治疗中重度急性呼吸窘迫综合征的临床研究

The clinical research about airway pressure release ventilation for moderate to severe acute respiratory distress syndrome

目的：评价气道压力释放通气（ APRV）对中重度急性呼吸窘迫综合征（ ARDS）患者的临床疗效。方法2012－08～2014－08中重度ARDS患者52例，随机分为两组， APRV组（n＝26）采用气道压力释放通气；小潮气量肺保护通气组（n＝26）采用容量同步间歇指令通气＋呼气末正压（ SIMV＋PEEP），根据准静态PV曲线，测定低位转折点设置PEEP。监测两组机械通气时及机械通气后12、24、48、72 h氧合指标、呼吸力学、血管外肺水、功能残气量变化及血流动力学的改变；测定两组通气24、48、72 h后肺泡灌洗液TNF－α和IL－10浓度变化。记录机械通气第1、2、3天APACHEⅡ评分、Murray急性肺损伤评分；记录通气期间气胸、纵隔气肿等严重呼吸机相关性肺损伤事件。观察患者28 d生存率、28 d脱离呼吸机时间、无脏器衰竭时间及无镇静剂使用时间。结果与SIMV组比较，APRV组APRV 48 h前PaO2／FiO2升高，同时Ppeak降低，动态顺应性、血管外肺水、功能残气量及Murray急性肺损伤评分改善（P＜0．05）；APRV组CVP、SVRI降低，同时CI升高（P＜0．05），48 h前Lac及ScvO2好转（P＜0．05），72 h各指标比较差异无统计学意义；28 d内镇静使用时间减少[（22．4±8．5）d vs （17．1±8．6）d]，28 d内脱离呼吸机时间增加[（19．6±8．2）d vs （15．1±8．9）d]，住ICU时间缩短[（7．4±3．3）d vs （9．5±3．2）d]（P均＜0．05）；而肺泡灌洗液TNF－α、IL－10浓度及病死率比较差异无统计学意义（P＞0.05）。结论APRV用于中重度ARDS患者的机械通气治疗，不仅能及早地提供更好的呼吸支持，改善肺功能，而且能够改善早期血流动力学，减少镇静剂使用时间和机械通气时间，缩短住ICU时间。

Objective Evaluation of clinical effect of airway pressure release ventilation （ APRV） in patients with moderate to severe acute respiratory distress syndrome （ ARDS） .Methods 52 cases with moderate to severe ARDS were randomly divided into two groups from August 2012 to August 2014 in our hospital.APRV group （n=26） were used airway pressure release ventilation;Small tidal volume lung protection ventilation group （ n =26 ） were ventilated by synchronized intermittent mandatory ventilation mode and PEEP （ SIMV ＋PEEP）.PEEP was set by low inflation pressure according to measurement with the quasi-static PV curve.Changes were recorded at 12 h, 24 h, 48 h, 72 h in the two groups after mechanical ventilation, such as oxygenation index, respiratory mechanics, extravascular lung water, functional residual capacity change and hemodynamics.The level of TNF-αand IL-10 were measued in alveolar lavage after 24 h, 48 h and 72 h ventilation.Scores of APACHEⅡ s and Murray were evaluated after 1, 2, 3 days ventilation.Also pneumothorax and mediastinal emphysema during ventilation were recorded.Probability of survival, the days of weaning, in ICU, without organ failure and without sedatives days within 28 days were compared.Results Compared with changes in SIMV group, those changes in APRV group were improved significantly during 48 h ventilation, such as increased oxygenation index, reduced Ppeak, improved the lung dynamic compliance, relieved extravascular lung water, increased functional residual capacity and improved Murray（P〈0.05）.Indicates of CVP, SVRI is reduced, and CI increased （P〈0.05） in APRV group during 48 h ventilation.At the same time lac and ScvO2 improved （P〈0.05）.There was no obviously differences in two groups after 48 h ventilation.The days with free sedatives within 28 d [ （22.4 ±8.5） vs （17.1±8.6） d] were significantly reduced in APRV group.The days of free of mechanical ventilation within 28 d[ （19.6 ±8.2） vs （15.1 ±8.9） d] were increased significantly; days in ICU significantly were shortened [d （7.4 ±3.3） vs （9.5 ±3.2） d]（P〈0.05）.But the concentrations of TNF-αand IL-10 in the alveolar lavage, Probability of survival and days without organ failure within 28 days were similar （P〉0.05）.Conclusion In patients with moderate to severe ARDS, application with APRV can early improve lung function and hemodynamics, but also reduce sedative use and the duration of mechanical ventilation.At same time it can cut short days in ICU.