跨肺压导向急性呼吸窘迫综合征患者最佳呼气末正压选择的临床研究

The selection of optimal positive end expiratory pressure in patients with transpulmonary pressure guidance acute respiratory distress syndrome

目的研究跨肺压导向急性呼吸窘迫综合征(ARDS)患者最佳呼气末正压(PEEP)选择的临床意义。方法选择需要进行机械通气的跨肺压导向ARDS患者68例,随机分为对照组和观察组,每组34例。观察组患者在进行充分肺腹张后,调整PEEP至30 cm H2O(1 cm H2O=0.098 k Pa),每隔5分钟降低3 cm H2O,直至降为0,在PEEP递减过程中分别采用跨肺压法、最小死控分数法、最大顺应性法,最佳氧合法选择最佳的PEEP对呼吸力学及气体交换。对照组采用常规治疗方式。分别监测2组患者在治疗前后48、72 h的氧合指数,经皮脉氧饱和度、肺顺应性、平均动脉压(MAP)、治疗后4周病死率的情况。结果 2组患者治疗前氧合指数和Sp O2差异无统计学意义(P>0.05)。治疗后48、72 h氧合指数比较均比治疗前高,且观察组优于对照组,差异均有统计学意义(P<0.05)。治疗前观察组的肺顺应性和MAP指数和对照组比较,差异无统计学意义(P>0.05)。治疗后48 h观察组肺顺应性明显优于对照组(P<0.01)。跨肺压法、最小死控分数法、最大顺应性法,最佳氧合法的PEEP数值对比均高于基础状态,最佳氧合法的数值较其他三种方法显著升高(P<0.05)。跨肺压法、最小死控分数法、最大顺应性法之间比较差异无统计学意义(P>0.05)。结论 ARDS机械通气患者采用跨肺压法选择最佳PEEP,在保证能促进塌陷肺泡腹张情况下,还可以有效改善氧合和肺顺应性,同时还能避免导致肺泡过度膨胀。

Objective To investigate the clinical significance of selection of optimal positive end expiratory pressure（ PEEP） in patients with transpulmonary pressure guidance acute respiratory distress syndrome（ ARDS）. Methods A total of68 patients with PEEP respiratory distress syndrome who were admitted and treated by mechanical ventilation in our hospital from September 2015 to September 2016 were randomly divided into control group and observation group,with 34 patients in each group. After full abdominal expansion,the patients in observation group were treated by adjusting PEEP to 30 cm H2 O（ 1 cm H2 O= 0. 098 k Pa）,then decreasing 3 cm H2 O at 5 minutes interval,until PEEP was reduced to 0,moreover,during PEEP decrement,the transpulmonary pressure method,minimum fraction method,maximum compliance method,minimum dead control score method,optimal oxygenation method were used respectively to select the optimal PEEP for respiratory mechanics and gas exchange. However the patients in control group were treated by conventional therapy. The oxygenation index,percutaneous arterial oxygen saturation,lung compliance,mean arterial pressure at 48 h,72 h before and after treatment were observed and compared between two groups. Moreover the fatality rates after 4-week treatment were observed and compared between two groups. Results Before treatment there were no significant differences in oxygenation index and Sp O2 between two groups（ P〉 0. 05）,however,at 48 h,72 h after treatment the oxygenation index and Sp O2 were increased in both groups,moreover,which in observation group were superior to those in control group（ P〉 0. 05）. Before treatment there were no significant differences in pulmonary compliance and MAP index between two groups（ P〉 0. 05）,however,at 48 h after treatment,the pulmonary compliance in observation group was superior to that in control group（ P〉 0. 05）. The PEEP levels of transpulmonary pressure method,minimum dead control score method,maximum compliance method and optimal oxygenation method were significantly higher than those of baseline,moreover the PEEP levels of optimal oxygenation method were significantly higher than those of the other three methods（ P〉 0. 05）. However there were no significant differences in PEEP levels among transpulmonary pressure method,minimum dead control score method,maximum compliance method（ P〈 0. 05）. Conclusion The application of transpulmonary pressure method to select optimal PEEP in patients with ARDS receiving mechanical ventilation can effectively mprove oxygenation and lung compliance,moreover,which can avoid excessive expansion of pulmonary alveoli.