食道压指导呼气末正压设置行机械通气治疗创伤性颅脑损伤合并急性呼吸窘迫综合征患者的效果

Effects of positive end-expiratory pressure setting of mechanical ventilation guided by esophageal pressure in the treatment of patients with traumatic craniocerebral injury combined with acute respiratory distress syndrome

目的探讨食道压指导呼气末正压(PEEP)设置对行机械通气治疗创伤性颅脑损伤合并急性呼吸窘迫综合征(ARDS)患者的效果。方法采用回顾性队列研究方法。2016年6月—2018年6月,郑州大学附属郑州中心医院收治55例符合入选标准的创伤性颅脑损伤合并ARDS的患者,按照PEEP设置方法分为食道压组28例[男17例、女11例,年龄(40±13)岁]和PEEP-吸入气氧浓度(FiO_(2))表组27例[男18例、女9例,年龄(38±10)岁]。2组患者按肺保护性通气策略进行机械通气治疗,并分别根据食道压、PEEP-FiO_(2)表选定治疗0(即刻)、24、48、72 h的最佳PEEP,按照所得最佳PEEP调整机械通气参数。记录2组患者治疗24、48、72 h的呼气末跨肺压、肺顺应性、氧合指数、中心静脉压、平均动脉压、颅内压变化。对数据行重复测量方差分析、χ^(2)检验、独立样本t检验及Bonferroni校正。结果食道压组患者治疗0、24、48、72 h最佳PEEP分别为(12.4±3.9)、(11.2±3.5)、(13.4±2.6)、(13.2±3.6)cmH_(2)O(1 cmH_(2)O=0.098 kPa),明显高于PEEP-FiO_(2)表组的(8.2±2.5)、(7.4±2.2)、(8.3±2.3)、(8.5±2.5)cmH_(2)O,t=4.702、4.743、7.849、5.623,P<0.01。食道压组患者治疗24、48、72 h呼气末跨肺压、肺顺应性明显高于PEEP-FiO_(2)表组(t=17.852、20.586、19.532,4.752、5.256、7.446,P<0.01),治疗48、72 h氧合指数明显高于PEEP-FiO_(2)表组(t=2.342、4.178,P<0.05或P<0.01)。食道压组患者治疗24、48、72 h中心静脉压明显高于PEEP-FiO_(2)表组(t=12.632、5.247、8.994,P<0.01),2组患者治疗24、48、72 h平均动脉压相近(P>0.05)。食道压组患者治疗24、48、72 h颅内压高于PEEP-FiO_(2)表组,但差异无统计学意义(P>0.05)。结论对创伤性颅脑损伤合并ARDS的患者,可利用食道压法指导选定最佳PEEP,并根据最佳PEEP调整机械通气参数,能更有效改善肺顺应性、加速肺功能恢复,同时不影响平均动脉压及颅内压。

Objective To investigate the effects of positive end-expiratory pressure(PEEP)setting of mechanical ventilation guided by esophageal pressure in the treatment of patients with traumatic craniocerebral injury combined with acute respiratory distress syndrome(ARDS).Methods The retrospective cohort study was conducted.From June 2016 to June 2018,55 patients with traumatic craniocerebral injury combined with ARDS who met the inclusion criteria were admitted to Zhengzhou Central Hospital Affiliated to Zhengzhou University.According to PEEP setting method,28 patients were allocated to esophageal pressure group(17 males and 11 females,aged(40±13)years)and 27 patients were allocated to PEEP-fractional concentration of inspired oxygen(FiO_(2))table group(18 males and 9 females,aged(38±10)years).Patients in the 2 groups were treated with mechanical ventilation guided by lung protective ventilation strategy,and the optimal PEEP at 0(immediately),24,48,and 72 h after treatment was determined according to esophageal pressure and PEEP-FiO_(2) table,respectively.The mechanical ventilation parameters in the 2 groups were adjusted according to the optimal PEEP.The transpulmonary end-expiratory pressure,pulmonary compliance,oxygen index,central venous pressure,mean arterial pressure,and intracranial pressure at 24,48,and 72 h after treatment were recorded.Data were statistically analyzed with analysis of variance for repeated measurement,chi-square test,independent sample t test,and Bonferroni correction.Results The optimal PEEP of patients in esophageal pressure group at 0,24,48,and 72 h after treatment was(12.4±3.9),(11.2±3.5),(13.4±2.6),and(13.2±3.6)cmH_(2)O(1 cmH_(2)O=0.098 kPa),respectively,which was significantly higher than(8.2±2.5),(7.4±2.2),(8.3±2.3),and(8.5±2.5)cmH_(2)O in PEEP-FiO_(2) table group,respectively(t=4.702,4.743,7.849,5.623,P<0.01).The transpulmonary end-expiratory pressure and pulmonary compliance at 24,48,and 72 h after treatment and oxygen index at 48 and 72 h after treatment of patients in esophageal pressure group were significantly higher than those in PEEP-FiO_(2) table group(t=17.852,20.586,19.532,4.752,5.256,7.446,2.342,4.178,P<0.05 or P<0.01).The central venous pressure of patients in esophageal pressure group at 24,48,and 72 h after treatment was significantly higher than that in PEEP-FiO_(2) table group(t=12.632,5.247,8.994,P<0.01),and there was no statistically significant difference in mean arterial pressure of patients between the 2 groups at 24,48,and 72 h after treatment(P>0.05).The intracranial pressure of patients in esophageal pressure group was higher than that in PEEP-FiO_(2) table group at 24,48,and 72 h after treatment,but there was no statistically significant difference between the 2 groups(P>0.05).Conclusions For patients with traumatic craniocerebral injury combined with ARDS,the optimal PEEP can be set under the guidance of esophageal pressure method,and the mechanical ventilation parameters adjusted according to the optimal PEEP can improve lung compliance and accelerate recovery of lung function more effectively,with no adverse effect in mean arterial pressure and intracranial pressure.