呼气末正压和吸氧浓度调整顺序对急性呼吸窘迫综合征机械通气恢复期病人肺部损伤的影响

The effects of adjusting sequence of PEEP and oxygen inhalation on lung injury in patients with ARDS in the recovery period of mechanical ventilation

目的探究呼气末正压(PEEP)和吸氧浓度(FiO_(2))调整顺序对急性呼吸窘迫综合征(ARDS)机械通气恢复期病人肺部损伤的影响。方法选取2016年7月至2020年8月在河北省人民医院急诊重症监护室(EICU)就诊的80例需机械通气的ARDS病人,采用随机数字表法分为PEEP固定组和FiO_(2)固定组,各40例。两组病人均采用肺保护性通气策略。病情稳定后,PEEP固定组维持呼吸机参数不变(PEEP=12~15 cmH_(2)O),FiO_(2)逐渐调整为80%、60%、40%;FiO_(2)固定组维持FiO_(2)=60%不变,PEEP水平逐渐调整为12、10、8 cm H_(2)O。对比不同时间肺泡灌洗液(BALF)中肿瘤坏死因子(TNF-α)、白细胞介素-6(IL-6)和肺表面活性蛋白A(SP-A)水平。结果随着PEEP水平和FiO_(2)的降低,两组病人TNF-α、IL-6和SP-A水平呈下降趋势;但调整参数1 h后,TNF-α、IL-6和SP-A水平升高。两组病人在调整FiO_(2)=40%、PEEP=8 cm H_(2)O前0 h,TNF-α、IL-6和SP-A水平最低,且FiO_(2)固定组低于PEEP固定组(P<0.05)。结论降低PEEP水平和FiO_(2)有利于减轻ARDS病人炎症反应及降低SP-A水平,先降低PEEP水平后降低FiO_(2),对ARDS机械通气恢复期病人肺部炎性损伤的改善作用较好。

Objective To explore the effect of adjusting sequence of positive end expiratory pressure(PEEP) and inspired oxygen concentration(FiO_(2)) on lung injury in patients with acute respiratory distress syndrome(ARDS) in the recovery period of mechanical ventilation.Methods Eighty ARDS patients in need of mechanical ventilation who were treated in the Emergency Intensive Care Unit(EICU) of Hebei Provincial People's Hospital from July 2016 to August 2020 were randomly assigned into PEEP fixation group and FiO_(2) fixation group,with 40 cases in each group.Both groups adopted lung protective ventilation strategies.After the condition was stable,the PEEP fixation group maintained the same ventilator parameters(PEEP=12-15 cm H_(2)O),and the FiO_(2) was gradually adjusted to 80%,60%,40%,while the FiO_(2) fixation group maintained FiO_(2) at 60% unchanged,and the PEEP level was gradually adjusted to 12,10,8 cm H_(2)O.A comparison was made between the levels of tumor necrosis factor(TNF-α),interleukin-6(IL-6) and pulmonary surfactant protein A(SP-A) in bronchoalveolar lavage fluid(BALF) at different times.Results As the levels of PEEP and FiO_(2) decreased,the levels of TNF-α,IL-6 and SP-A in the two groups showed a downward trend;but 1 h after adjusting the parameters,the levels of TNF-α,IL-6 and SP-A increased.The patients in both groups had the lowest levels of TNF-α,IL-6 and SP-A 0 h before adjusting FiO_(2)to 40% and PEEP to 8 cm H_(2)O,and they were lower in the FiO_(2) fixation group than the PEEP fixation group(P0.05).Conclusions Reducing the levels of PEEP and FiO_(2) is beneficial to alleviating the inflammatory response and reducing SP-A level in patients with ARDS.Lowering the level of PEEP first and then reducing FiO_(2) has a better effect on improving the lung inflammatory injury in ARDS patients with in the recovery period of mechanical ventilation.