俯卧位通气对伴间质性肺疾病的急性呼吸窘迫综合征患者血流动力学的影响

Effect of Prone Position Ventilation on Hemodynamics in Patients with Interstitial Lung Disease Concurrent with Acute Respiratory Distress Syndrome

目的探讨俯卧位通气(PPV)对伴或不伴间质性肺疾病(ILD)的急性呼吸窘迫综合征(ARDS)患者血流动力学的影响。方法收集重症医学科2013至2015年应用了PPV的中重度ARDS患者,回顾脉搏指示连续心排出量监测(Pi CCO)指标[平均动脉压(MAP)、心排指数(CI)、胸腔内血容量指数(ITBVI)等]在俯卧位前2 h(PPV-2)、俯卧位后(PPVmean)和恢复仰卧位2 h(PPV+2)的变化情况,以及PPV整体治疗前后的心脏、肝、肾、凝血等功能的变化情况。结果共入选重度肺内源性ARDS患者36例,开始PPV治疗前去甲肾上腺素用量(0.14±0.10)μg·kg-1·min-1,血乳酸水平(1.70±0.57)mmol/L。血流动力学变化:与PPV-2比较,所有患者PPVmean的CI呈上升趋势[(4.06±0.95)L·min-1·m-2比(3.98±1.05)L·min-1·m-2,P>0.05],Scv O2、ITBVI明显上升[(76.94±8.94)%比(70.67±8.23)%,(982.17±245.87)m L/m2比(912.97±177.65)m L/m2,P<0.05],HR、MAP、每小时尿量均有下降趋势(P>0.05)。按伴或不伴ILD分两组,ILD组17例,非ILD组19例,两组基线资料差异无统计学意义(P>0.05)。与PPV-2比较,ILD组PPV+2的MAP下降明显[(85.44±10.84)mm Hg比(89.21±10.92)mm Hg,P<0.05];与PPVmean比较,ILD组在PPV+2的CI下降明显[(3.43±0.72)L·min-1·m-2比(3.74±0.87)L·min-1·m-2,P<0.05)。PPV治疗结束后与开始PPV前比较,非ILD组的活化部分凝血活酶时间显著延长[(67.04±97.52)s比(41.24±8.72)s,P<0.05]、BUN显著升高[(10.64±4.95)μmol/L比8.18±3.88)μmol/L,P<0.05],ILD组以上各指标变化差异无统计学意义。结论伴或不伴ILD的中重度ARDS患者行PPV均不影响心排出量,且可增加回心血量,改善组织的灌注,但腹腔脏器的灌注需要更密切的监测。

Objective To investigate the effect of prone position ventilation（ PPV） on hemodynamics in patients with interstitial lung disease（ ILD） concurrent with acute respiratory distress syndrome（ ARDS） or not. Methods Severe ARDS patients received PPV treatment in intensive care unit from 2013 to 2015 were retrospectively analyzed. Pulse index continuous cardiac output（ Pi CCO） monitoring indices were compared 2h before PPV（ PPV- 2）,in-PPV（ PPVmean） and 2h after turn back to supine position（ PPV ＋ 2）,including mean arterial pressure（ MAP）,cardiac index（ CI）,intrathoracic blood volume index（ ITBVI）,etc. Heart function,liver function,renal function,coagulative function were compared before and after all the PPV treatment. Results Thirty-six severe pulmonary ARDS patients were recruited. Norepinephrine（ NE） dose was（ 0. 14 ± 0. 10） μg·kg^-1·min^-1and lactate concentration was（ 1. 70 ± 0. 57） mmol/L before PPV. CI in all the patients was increased [（ 4. 06 ± 0. 95） L·min^-1·m^-2vs.（ 3. 98 ± 1. 05） L·min^-1·m^-2,P〈0. 05） and central venous oxygen saturation,ITBVI [（ 76. 94 ±8. 94） % vs.（ 70. 67 ± 8. 23） %,（ 982. 17 ± 245. 87） m L / m2 vs.（ 912. 97 ± 177. 65） m L / m2,P〈0. 05） ] were significantly increased compared with PPV- 2,while heart rate（ HR）,MAP,urine volume were decreased（ P〈0. 05）. The patients were divided into an ILD group（ n = 17） and a non-ILD group（ n = 19）,and no significant differences were found in baseline data between two groups. Compared with PPV- 2,MAP was significant decreased at PPV ＋ 2 [（ 85. 44 ± 10. 84） mm Hg vs.（ 89. 21 ± 10. 92） mm Hg,P〈0. 05） in the ILD group. Compared with PPVmean,CI was obviously declined at PPV ＋ 2 in the ILD group. Activated partial thromboplastin time was increased [（ 67. 04 ± 97. 52） s vs.（ 41. 24 ± 8. 72） s,P〈0. 05] and BUN was higher [（ 10. 64 ± 4. 95） μmol / L vs.（ 8. 18 ± 3. 88） μmol / L,P〈0. 05] in the ILD group,while no significant difference was found in the non-ILD group. Conclusion PPV will not affect cardiac output in severe ARDS patients with ILD. It can increase venous return and improve tissue perfusion,but the perfusion of the abdomen organ need to be monitored cautiously.