右心保护性通气策略在急性呼吸窘迫综合征患者中的应用:一项前瞻性随机对照研究

Application of right heart protective ventilation in acute respiratory distress syndrome patients:a prospective randomized controlled trail

目的探讨右心保护性通气策略对急性呼吸窘迫综合征(ARDS)患者右心功能及预后的影响.方法采用前瞻性随机对照研究方法,选取2021年1月至2022年9月于陕西省人民医院住院的83例ARDS患者,随机分为对照组(41例)及观察组(42例).对照组采用传统肺保护性通气,观察组采用右心保护性通气.采用超声心动图评价两组患者的右心收缩及舒张功能,记录呼吸机参数和血气分析结果,进行呼吸力学监测并记录28 d病死率、机械通气时间、体外膜肺氧合(ECMO)和俯卧位比例及时间预后指标.结果机械通气72 h后,观察组呼吸系统顺应性、潮气量、呼吸频率、气道峰压、平台压、驱动压、Tei指数、右心室面积变化分数(RVFAC)、右心室与左心室舒张末期直径比值(R/L)均较基础值有所改善(P均<0.05);且平台压、驱动压、Tei指数、三尖瓣外侧瓣环的组织多普勒频谱(E/e')均较对照组显著降低,三尖瓣环收缩期位移(TAPSE)、RVFAC、三尖瓣环收缩期速度(TAM)、三尖瓣血流多普勒频谱(E/A)均较对照组显著升高(P均<0.05).观察组机械通气时间明显短于对照组[(10±3)d vs.(14±6)d,t=2.306,P=0.026];而观察组与对照组患者28 d病死率[38.1%(16/42)vs.63.4%(26/41),χ^(2)=2.805,P=0.099],住ICU时间[(17±6)d vs.(17±7)d,t=0.152,P=0.873],液体平衡量[2876.8(1062.9,3399.6)mL vs.1458.7(-150.2,3821.4)mL,Z=0.364,P=0.750],俯卧位[47.6%(20/42)vs.41.5%(17/41),χ^(2)=0.660,P=0.360]、ECMO[40.5%(17/42)vs.31.7%(13/41),χ^(2)=1.850,P=0.177]及血管活性药物使用[40.5%(17/42)vs.48.8%(20/41),χ^(2)=1.122,P=0.289]比例比较,差异均无统计学意义.结论对ARDS患者给予右心保护性通气策略,与传统肺保护性通气策略有效性一致,并可降低右心障碍发生率,对右心收缩及舒张功能影响均较小,对右心功能有保护作用.

Objective To investigate the effect of right heart protective ventilation strategy on right heart function and prognosis in patients with acute respiratory distress syndrome(ARDS).Methods Using a prospective randomized controlled trial(RCT)method,83 patients with ARDS who were hospitalized in Shaanxi Provincial People's Hospital from January 2021 to September 2022 were selected and randomly divided into a control group(n=41)and a observation group(n=42).The control group was treated with conventional lung protective ventilation,and the observation group was treated with right heart protective ventilation.Echocardiography was performed to evaluate right heart systolic and diastolic function.The ventilator parameters,blood gas analysis results,and prognostic indicators such as 28-day mortality,duration of mechanical ventilation,extracorporeal membrane oxygenation(ECMO),and prone position ratio and time were recorded respectively.Results After 72 hours of mechanical ventilation,the respiratory compliance,tidal volume,respiratory rate,peak airway pressure,plateau pressure,driving pressure,Tei index,right ventricular fractional area change(RVFAC),right/left ventricular end-diastolic diameter(R/L)in the observation group were all improved as compared with the basal values(all P<0.05).The plateau pressure,driving pressure,Tei index,and tissue Doppler velocities of the tricuspid annulus(E/e')were significantly lower,while the tricuspid annular plane systolic excursion(TAPSE),RVFAC,tricuspid annular motion(TAM),and Doppler velocities of the transtricuspid flow(E/A)were higher in the observation group than in the control group(all P<0.05).The duration of mechanical ventilation in the observation group was shorter than that in the control group[(10±3)d vs.(14±6)d,t=2.306,P=0.026].The 28-day mortality[38.1%(16/42)vs.63.4%(26/41),χ^(2)=2.805,P=0.099],ICU stay[(17±6)d vs.(17±7)d,t=0.152,P=0.873],amount of fluid[2876.8(1062.9,3399.6)mL vs.1458.7(-150.2,3821.4)mL,Z=0.364,P=0.750],proportion of prone position[47.6%(20/42)vs.41.5%(17/41),χ^(2)=0.660,P=0.360],ECMO[40.5%(17/42)vs.31.7%(13/41),χ^(2)=1.850,P=0.177],and proportion of vasoactive drug use[40.5%(17/42)vs.48.8%(20/41),χ^(2)=1.122,P=0.289]in the observation group and control group showed no statistically significant difference.Conclusions The right heart protective ventilation strategy given to ARDS patients is consistent with the effectiveness of the conventional lung protective ventilation strategy.It can reduce the incidence of right heart disorders,and has a protective effect on right heart function with less impact on both systolic and diastolic function.