纤支镜肺泡灌洗痰热清联合乌司他丁对心脏术后急性呼吸窘迫综合征患者肺循环功能、心功能的影响

Effects of Tanreqing by bronchofibroscope bronchoalveolar lavage combined with ulinastatin on pulmonary circulation and cardiac function in patients with acute respiratory distress syndrome after cardiac surgery

目的观察纤支镜肺泡灌洗痰热清联合乌司他丁对心脏术后急性呼吸窘迫综合征患者肺循环功能、心功能的影响。方法将2015年1月-2017年12月咸宁市中心医院收治的72例行心脏术后发生急性呼吸窘迫综合征患者随机分为对照组和观察组,每组36例。2组均采用常规术后支持治疗和机械通气,对照组给予注射用乌司他丁,观察组在对照组的基础上联合痰热清纤支镜肺泡灌洗,疗程均为7 d。测定治疗前后2组患者动脉血pH值、二氧化碳分压[p(CO2)]、氧分压[p(O2)]和动脉血氧饱和度[Sa(O2)],计算p(O2)/Fi(O2)。分别于治疗前后抽取患者晨起空腹肘静脉血5 mL,检测肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)和白细胞介素-8(IL-8)水平。监测2组患者肺循环阻力(PVR)、平均肺动脉压(MPAP)、肺毛细血管楔压(PCWP)、血管外肺水指数(EVLWI)、肺血管通透性指数(PVPI)、三尖瓣口肺动脉压力(TPAP)、中心静脉压(CVP)和心排指数(CI),超声心动图测定2组患者右室每搏功指数(RVSWI)、右心室射血分数(RVEF)、右心室收缩末期容积指数(RVEDVI)、右心室做功指数(RCWI)、右心室室壁应力(RVWS),比较2组患者的机械通气时间、ICU停留时间、住院时间、住院费用和病死率。结果 2组治疗后pH、p(O2)、Sa(O2)和p(O2)/Fi(O2)均明显升高(P均<0.05),p(CO2)明显降低(P均<0.05),且观察组变化的程度均明显大于对照组(P均<0.05)。2组治疗后血清TNF-α、IL-6、IL-8水平及PVR、MPAP、PCWP、EVLWI、PVPI、TPAP、CVP、RVEDVI、RVWS均明显降低(P均<0.05),且观察组明显低于对照组(P均<0.05)。2组治疗后CI、RVSWI、RVEF、RCWI均明显升高(P均<0.05),且观察组明显高于对照组(P均<0.05)。观察组治疗后机械通气时间、ICU停留时间、住院时间均明显短于对照组(P均<0.05),住院费用明显少于对照组(P<0.05),病死率明显低于对照组(P<0.05)。结论纤支镜肺泡灌洗痰热清联合乌司他丁可以改善心脏术后急性呼吸窘迫综合征患者的动脉血气指标、肺循环功能、心功能和临床结局,其机制可能与有效降低炎性因子TNF-α、IL-6、IL-8水平有关。

Objective It is to observe the effects of Tanreqing by bronchofibroscope bronchoalveolar lavage combined with ulinastatin on pulmonary circulation and cardiac function in patients with acute respiratory distress syndrome after cardiac surgery. Methods Seventy-two patients with acute respiratory distress syndrome after cardiac surgery were randomly divided into a control group and an observation group, with 36 cases in each group. Both groups were treated with conventional postoperative support and mechanical ventilation. The control group was given ulinastatin injection. The observation group was given Tanreqing by bronchofibroscope bronchoalveolar lavage on the basis of the control group. The treatment courses were both 7 days. The arterial blood pH, partial carbon dioxide pressure [p(CO2)], partial oxygen pressure [p(O2)], and arterial oxygen saturation [Sa(O2)] were measured and p(O2)/Fi(O2) was calculated before and after treatment in the two groups. Before and after treatment, 5 mL of fasting elbow venous blood was collected from patients in the morning to detect the levels of tumor necrosis factor-α(TNF-α), interleukin-6(IL-6) and interleukin-8(IL-8). The pulmonary vascular resistance(PVR), mean pulmonary artery pressure(MPAP), pulmonary capillary wedge pressure(PCWP), extravascular lung water index(EVLWI), pulmonary vascular permeability index(PVPI), tricuspid pulmonary artery pressure(TPAP), central venous pressure(CVP), and cardiac output index(CI) were detected, the right ventricular stroke work index(RVSWI), right ventricular ejection fraction(RVEF), right ventricular end-systolic volume index(RVEDVI), right ventricular work index(RCWI), and right ventricular wall stress(RVWS) were detected by echocardiography in the two groups. Mechanical ventilation time, ICU stay time, length of hospital stay, hospitalization cost, and mortality were compared between the two groups. Results After treatment, the pH, p(O2), Sa(O2), and p(O2)/Fi(O2) were significantly increased while p(CO2) was significantly reduced in the two groups(P<0.05), and the degree of change in the observation group was more significant than that in the control group(P<0.05). After treatment, the levels of serum TNF-α, IL-6, IL-8, and PVR, MPAP, PCWP, EVLWI, PVPI, TPAP, CVP, RVEDVI, and RVWS were significantly reduced in the two groups(P<0.05), and the indexes in the observation group were significantly lower than those in the control group(P<0.05);CI, RVSWI, RVEF, and RCWI were significantly increased in the two groups after treatment(P<0.05), and the indexes in the observation group were significantly higher than those in the control group(P<0.05). The mechanical ventilation time, ICU stay time, and hospital stay in the observation group were significantly shorter(P<0.05), the hospital costs and mortality were significantly lower than those in the control group(P<0.05). Conclusion Tanreqing by bronchofibroscope bronchoalveolar lavage combined with ulinastatin can improve the arterial blood gas indexes, pulmonary circulation function, cardiac function and clinical outcome in patients with acute respiratory distress syndrome after cardiac surgery, and its mechanism may be related to effectively reducing the levels of inflammatory factor TNF-α, IL-6, IL-8.