保护性肺通气序贯肺复张治疗重症急性胰腺炎并发ARDS的临床研究

A clinical study of lung protective ventilation and sequential lung recruitment maneuver for treatment of severe acute pancreatitis complicated with acute respiratory distress syndrome

目的 观察保护性肺通气序贯肺复张（RM）治疗重症急性胰腺炎（SAP）并发急性呼吸窘迫综合征（ARDS）患者的临床疗效.方法 选择南昌大学第一附属医院重症医学科2014年4月至2016年3月收治的60例SAP并发ARDS患者,将患者按随机数字表法分为对照组和试验组,每组30例.对照组在综合治疗基础上采用保护性肺通气模式,即小潮气量（6 mL/kg）＋最佳呼气末正压（PEEP）的通气模式,试验组当腹腔内压（IAP）基本恢复正常（Ⅰ级腹腔高压）时联合RM治疗,其余同对照组.比较两种通气策略下患者的临床疗效、呼吸力学、血流动力学及动脉血气等指标的差异.结果 试验组治疗后机械通气时间（d：13.82±4.40比19.87±7.40）、ICU住院时间（d：22.67±4.40比26.43±5.39）、呼吸机相关性肺炎（VAP）发生率〔16.67%（5/30）比26.67%（8/30）〕均较对照组明显降低（均P〈0.05）,病死率较对照组有所降低〔26.67%（8/30）比30.00%（9/30）〕,但两组比较差异无统计学意义（P〉0.05）.两组治疗后各时间点气道平台压（Pplat）、气道峰压（PIP）均较治疗前下降,肺静态顺应性（Cst）、动脉血氧分压（PaO2）、氧合指数（PaO2/FiO2）均较治疗前升高,且以试验组治疗后72 h的变化较对照组更显著〔Pplat（cmH2O,1 cmH2O=0.098 kPa）：15.6±4.0比21.2±5.6,PIP（cmH2O）：18.3±5.0比25.1±5.4,Cst（mL/cmH2O）：41.2±4.8比31.2±6.0,PaO2（mmHg,1 mmHg=0.133 kPa）：90.93±6.45比80.27±4.51,PaO2/FiO2（mmHg）：238.33±18.31比185.83±11.14〕.试验组患者RM即刻血流动力学有一过性变化,心率〔HR（次/min）：110.23±7.92比98.23±8.44〕和中心静脉压〔CVP（mmHg）：8.62±1.52比6.32±1.42〕均较治疗前明显升高,平均动脉压〔MAP（mmHg）：86.74±7.65比94.92±10.93〕、心排血量〔CO（L/min）：5.32±1.36比6.42±1.32〕均较治疗前明显降低（均P〈0.05）,但RM结束后5 min血流动力学各项指标与治疗前比较差异无统计学意义（均P〉0.05）,RM后5 min HR、MAP、CVP、CO分别为（97.87±5.77）次/min、（94.54±6.87）mmHg、（6.33±1.44）mmHg、（6.32±1.41）L/min.结论 早期以保护性肺通气为基础,当IAP基本恢复正常后序贯RM治疗SAP并发ARDS,有利于改善肺顺应性,提高氧合,缩短机械通气时间和ICU住院时间,降低VAP的发生率,且对血流动力学无明显影响.

Objective To investigate the clinical therapeutic effects of lung protective ventilation and sequential recruitment maneuver （RM） on treatment of patients with severe acute pancreatitis （SAP） complicated with acute respiratory distress syndrome （ARDS）. Methods Sixty patients with SAP complicated with ARDS admitted to the Department of Critical Care Medicine of the First Affiliated Hospital of Nanchang University from April 2014 to March 2016 were enrolled. They were divided into control group and experimental group by random number table, 30 patients in each group. On the basis of comprehensive treatment, the patients in control group were treated with lung protective ventilation mode： low tidal volume ventilation （6 mL/kg） ＋ optimal end-expiratory positive pressure （PEEP） ventilation mode, when the intra-abdominal pressure （IAP） was essentially returned to a normal level （Ⅰ grade intra-abdominal hypertension）, the patients in experimental group were treated by the combination with RM therapy, and the rest treatment was the same as the control group. Under the two types of ventilation strategies, the clinical effects, respiratory mechanics, hemodynamics and arterial blood gas indexes were compared between the two groups. Results The mechanical ventilation time （days： 13.82±4.40 vs. 19.87±7.40）, the length of ICU stay （days：22.67±4.40 vs. 26.43±5.39） and incidence of ventilator associated pneumonia [VAP： 16.67% （5/30） vs. 26.67% （8/30）] of the experimental group were lower than those of the control group （all P〈0.05）, the mortality rate of the experimental group was slightly lower than that of the control group [26.67% （8/30） vs. 30.00% （9/30）] without statistical significance （P〉0.05）. Plateau pressure （Pplat） and the peak airway pressure （PIP） at each time point were decreased after treatment in both groups, while the static lung compliance （Cst）, the arterial partial pressure of oxygen （PaO2） and oxygenation index （PaO2/FiO2） were increased compared with those before treatment, especially the changes at 72 hours after recruitment in the experimental group were more significant than those in the control group [Pplat （cmH2O, 1 cmH2O = 0.098 kPa）：15.6±4.0 vs. 21.2±5.6, PIP （cmH2O）： 18.3±5.0 vs. 25.1±5.4, Cst （mL/cmH2O）： 41.2±4.8 vs. 31.2±6.0, PaO2 （mmHg, 1 mmHg = 0.133 kPa）： 90.93±6.45 vs. 80.27±4.51, PaO2/FiO2 （mmHg）： 238.33±18.31 vs. 185.83±11.14]. Heart rate [HR （bpm）： 110.23±7.92 vs. 98.23±8.44] and the central venous pressure [CVP （mmHg）： 8.62±1.52 vs. 6.32±1.42] were significantly higher than those before treatment, the mean arterial pressure [MAP （mmHg）： 86.74±7.65 vs. 94.92±10.93] and cardiac output [CO （L/min）： 5.32±1.36 vs. 6.42±1.32] were significantly reduced compared with those before treatment （all P 〈 0.05）. The values of HR, MAP, CVP, CO at 5 minutes after recruitment were （97.87±5.77） bpm, （94.54±6.87） mmHg, （6.33±1.44） mmHg, （6.32±1.41） L/min, respectively. The changes of these parameters were not significant when compared with those of the basal conditions （P〉0.05） Conclusions Based on the lung protective ventilation in the early stage, sequential RM is applied in treatment of patients with SAP complicated with ARDS, after the IAP is essentially returned to a normal, which is beneficial to improving lung compliance, promoting oxygenation, shortening the time of mechanical ventilation, reducing the length of ICU stay, and decreasing the incidence of VAP without any obvious hemodynamic influence.