动态FRC监测滴定最适PEEP在中重度ARDS患者中的应用

Application of Dynamic FRC Monitoring Titration Optimal PEEP in Patients with Moderate to Severe ARDS

目的 探讨基于动态功能残气量监测滴定中重度急性呼吸窘迫综合征(acute respiratory distress syndrome, ARDS)患者肺复张后呼吸末正压的可行性。方法 本研究依据实验设计的纳入和排除标准选取2020年6月至2021年12月在锦州医科大学附属第一医院重症监护病房行有创机械通气的80例ARDS患者作为研究对象,采用随机数字表法将患者分为试验组和对照组,所有入组患者在给予适当镇静、镇痛后进行充分肺复张,随后试验组通过动态监测功能残气量(functional residual volume, FRC)滴定最适呼吸末正压(positive end-expiratory pressure, PEEP)值,对照组则依据最大氧合法滴定最佳PEEP值。观察两组患者在有效的肺复张(positive end-expiratory pressure, RM)前后不同时间节点氧合指数、肺动态顺应性、气道峰压、炎症指标、机械通气时长、患者机械功等指标的差异性并进行统计学分析。结果 两组患者经适量镇静、镇痛后给予充分的RM,在相同时间观察点患者PaO2/FiO2、Cdyn均呈上升趋势,而PIP均呈下降趋势,两组间差异无统计学意义(P>0.05);试验组在复张后0.5、2 h观察到的PaO2/FiO2、Cdyn值均高于对照组,PIP值则低于对照组,差异有统计学意义(P<0.05)。RM前患者血液中炎性介质指标IL-6、IL-10较正常参考区间均升高,但两组间差异无统计学意义(P>0.05),RM后两组患者留取的血液标本中IL-6均呈下降趋势,IL-10均呈升高趋势。试验组在复张后24、48 h外周血中观察到的IL-6值高于对照组,IL-10值则低于对照组,差异有统计学意义(P<0.05)。最终试验组滴定PEEP值高于对照组,而试验组所需MP、患者机械通气时长均明显低于对照组,差异均有统计学意义(P<0.05)。结论 (1)最适FRC指导RM后滴定最佳PEEP的方法可以有效纠正患者的低氧血症并改善其氧合状态;(2)最适FRC指导RM后滴定最佳PEEP的方法具有减轻炎症因子释放,降低肺内炎症程度的作用。

Objective To investigate the feasibility of dynamic functional residual volume(FRC)based monitoring for titration of positive end-expiratory pressure(PEEP)after pulmonary resuscitation in patients with moderate to severe acute respiratory distress syndrome(ARDS).Methods In this study,80 patients with ARDS who underwent invasive mechanical ventilation in our intensive care unit from June 2020 to December 2021 were selected according to the inclusion and exclusion criteria of the experimental design,and the patients were divided into test and control groups using the random number table method,and all enrolled patients underwent adequate pulmonary resuscitation after being given appropriate sedation and analgesia(RM),followed by titration of the optimal PEEP value by monitoring FRC in the test group and titration of the optimal PEEP value based on the maximum oxygen law in the control group.The differences in oxygenation index(PaO 2/FiO 2),pulmonary dynamic compliance(Cdyn),peak airway pressure(PIP),inflammation index,duration of mechanical ventilation,and patient mechanical work(MP)at different time points before and after RM were observed and statistically analyzed in both groups.Results In both groups,patients were given adequate RM after moderate sedation and analgesia,and PaO 2/FiO 2 and Cdyn were on the rise at the same time observation point,while PIP were on the decline,and the difference between the two groups was not statistically significant(P>0.05);PaO 2/FiO 2 and Cdyn values of test group were higher than those of control group at 0.5 and 2 h after restretching,while PIP values were lower than those of control group,with statistical significance(P<0.05).The inflammatory mediators IL-6 and IL-10 in the blood of patients before RM were increased compared with the normal reference interval,but there was no statistical significance between the two groups(P>0.05).The IL-6 in the blood samples retained after RM showed a decreasing trend,while IL-10 showed an increasing trend.The IL-6 value in peripheral blood of the experimental group was higher than that of the control group at 24 and 48 h after reopening,while the IL-10 value was lower than that of the control group,with statistical significance(P<0.05).Finally,the titration PEEP value of the experimental group was higher than that of the control group,while the MP required by the experimental group and the mechanical ventilation duration of the patients were significantly lower than that of the control group,with statistical significance(P<0.05).Conclusion The optimal FRC-guided titration of optimal PEEP after RM can effectively correct hypoxemia and improve the oxygenation status of patients.The optimal FRC-guided titration of optimal PEEP after RM has the effect of reducing the release of inflammatory factors and decreasing the degree of inflammation in the lungs.