VV-ECMO单用与联用俯卧位通气在急性呼吸窘迫综合征治疗中的疗效比较

Comparison of efficacy between veno-venous extracorporeal membrane oxygenation(VV-ECMO)and VV-ECMO combined with prone position ventilation for the treatment of acute respiratory distress syndrome

目的观察静脉-静脉体外膜肺氧合(VV-ECMO)联合俯卧位通气(PPV)对重度急性呼吸窘迫综合征(ARDS)患者氧合指数(PaO_(2)/FiO_(2))、呼吸系统顺应性(Crs)、血管活性药物评分(VIS)的影响。方法采用回顾性观察性研究方法,选择2018年6月至2020年4月柳州市人民医院收治的18例需要VV-ECMO支持的重度ARDS患者作为研究对象,其中8例在VV-ECMO后实施PPV。比较VV-ECMO组与VV-ECMO联合PPV组治疗前和治疗1、2、3 d,以及VV-ECMO联合PPV组实施PPV 3 d内每日开始PPV前和PPV治疗结束后2 h PaO_(2)/FiO_(2)、VIS、Crs的差异;并观察两组患者不良事件发生情况。结果治疗前两组PaO_(2)/FiO_(2)、VIS比较差异均无统计学意义。随治疗时间延长,两组PaO_(2)/FiO_(2)、Crs均逐渐升高,VIS均逐渐降低,治疗1 d起PaO_(2)/FiO_(2)、VIS与治疗前比较差异有统计学意义〔PaO_(2)/FiO_(2)(mmHg,1 mmHg=0.133 kPa):VV-ECMO组为197.75±39.80比75.57±7.44,VV-ECMO联合PPV组为255.20±31.92比68.24±11.64;VIS(分):VV-ECMO组为5.51±3.72比10.20±7.10,VV-ECMO联合PPV组为6.73±3.32比14.50±2.48,均P<0.05〕,持续到治疗3 d〔PaO_(2)/FiO_(2)(mmHg):VV-ECMO组为231.96±32.76比75.57±7.44,VV-ECMO联合PPV组为285.61±19.40比68.24±11.64;VIS(分):VV-ECMO组为2.26±1.90比10.20±7.10,VV-ECMO联合PPV组为2.13±1.55比14.50±2.48,均P<0.05〕,且治疗1 d和3 d VV-ECMO联合PPV组PaO_(2)/FiO_(2)均明显高于VV-ECMO组(mmHg:1 d为255.20±31.92比197.75±39.80,3 d为285.61±19.40比231.96±32.76,均P<0.05)。治疗前VV-ECMO联合PPV组Crs明显低于VV-ECMO组(mL/cmH2O:17.91±0.82比20.54±1.26,P<0.05);VV-ECMO联合PPV组治疗1 d起Crs即明显高于治疗前(mL/cmH2O:21.20±1.50比17.91±0.82),治疗3 d达到峰值为(24.93±2.18)mL/cmH2O,但两组比较差异无统计学意义。VV-ECMO联合PPV组PPV1、2、3 d每日治疗后2 h PaO_(2)/FiO_(2)和Crs均较PPV治疗前明显升高,3 d时达到最高水平〔PaO_(2)/FiO_(2)(mmHg):285.61±19.40比189.91±28.34,Crs(mL/cmH2O):24.93±2.18比23.35±1.45,均P<0.05〕,VIS仅PPV治疗1 d后2 h较PPV前明显升高(分:6.73±3.32比6.38±3.22,P<0.05)。实施PPV后未发生与之相关的严重不良事件。结论 VV-ECMO期间联合PPV能更进一步提高PaO_(2)/FiO_(2),可更好地改善低氧血症,并有利于实施进一步的保护性肺通气策略以减少机械通气的危害。此外,未发现严重的不良事件,PPV在VV-ECMO期间是安全的。

Objective To observe the effects of veno-venous extracorporeal membrane oxygenation(VV-ECMO)combined with prone position ventilation(PPV)on oxygenation index(PaO_(2)/FiO_(2)),respiratory compliance(Crs)and vasoactive inotropic score(VIS)in severe acute respiratory distress syndrome(ARDS)patients.Methods Eighteen patients with severe ARDS requiring VV-ECMO support in Liuzhou People's Hospital from June 2018 to April 2020 were selected for retrospective analysis,and 8 patients among of these cases received PPV after VV-ECMO.The differences in PaO_(2)/FiO_(2),VIS and Crs before and 1,2 or 3 days after treatment were compared between VV-ECMO group and VV-ECMO combined with PPV group,as well as the differences in these indices before PPV and 2 hours after PPV daily in VV-ECMO combined with PPV group.The incidence of adverse events in two groups were also observed.Results Before treatment,there was no significant difference in PaO_(2)/FiO_(2),Crs between two groups.Over time,PaO_(2)/FiO_(2) and Crs increased and VIS decreased in both groups.Compared with before treatment,there were statistically significant differences in PaO_(2)/FiO_(2) and VIS from 1 day after treatment[PaO_(2)/FiO_(2)(mmHg,1 mmHg=0.133 kPa):VV-ECMO group was 197.75±39.80 vs.75.57±7.44,VV-ECMO combined with PPV group was 255.20±31.92 vs.68.24±11.64;VIS:VV-ECMO group was 5.51±3.72 vs.10.20±7.10,VV-ECMO combined with PPV group was 6.73±3.32 vs.14.50±2.48,all P<0.05],up to 3 days after treatment[PaO_(2)/FiO_(2)(mmHg):VV-ECMO group was 231.96±32.76 vs.75.57±7.44,VV-ECMO combined with PPV group was 285.61±19.40 vs.68.24±11.64;VIS:VV-ECMO group was 2.26±1.90 vs.10.20±7.10,VV-ECMO combined with PPV group was 2.13±1.55 vs.14.50±2.48,all P<0.05],and the PaO_(2)/FiO_(2)1 day and 3 days after treatment in VV-ECMO combined with PPV group were significantly higher than those in VV-ECMO group(mmHg:after 1 day of treatment was 255.20±31.92 vs.197.75±39.80,after 3 days of treatment was 285.61±19.40 vs.231.96±32.76,both P<0.05).Before treatment,Crs of VV-ECMO combined with PPV group was significantly lower than that of VV-ECMO group(mL/cmH2O:17.91±0.82 vs.20.54±1.26,P<0.05).From 1 day after treatment,the Crs in VV-ECMO combined with PPV group was significantly higher than that before treatment(mL/cmH2O:21.20±1.50 vs.17.91±0.82),the peak value was(24.93±2.18)mL/cmH2O on 3 days after treatment,however,there was no significant difference between the two groups(all P>0.05).In VV-ECMO combined with PPV group,compared with before PPV treatment,the PaO_(2)/FiO_(2) and Crs of 2 hours after PPV treatment in 1,2 and 3 days were significantly rose,and it reached the highest level in 3 days[PaO_(2)/FiO_(2)(mmHg):285.61±19.40 vs.189.91±28.34,Crs(mL/cmH2O):24.93±2.18 vs.23.35±1.45,both P<0.05];the VIS was only increased in 2 hours after PPV treatment on the first day than before(6.73±3.32 vs.6.38±3.22,P<0.05).There were no related serious adverse events happened after PPV treatment.Conclusions The combination of PPV during VV-ECMO could further increase PaO_(2)/FiO_(2),improve hypoxemia and implement further protective lung ventilation to reduce the potential hazards during mechanical ventilation.In addition,no serious adverse events were observed in this study,suggesting PPV is safe during VV-ECMO.