肺复张联合早期体外膈肌起搏对中重度ARDS患者的影响

Effect of Recruitment Maneuver Combined with Early External Diaphragm Pacing on Patients with Moderate to Severe ARDS

目的探讨肺复张(RM)联合早期体外膈肌起搏(EDP)治疗对中重度ARDS患者的影响。方法选取2022年1月至2023年9月在我院急诊监护室接受治疗的中重度ARDS患者57例。按照随机数字表法分为对照组(14例)、RM组(14例)、EDP组(14例)、RM+EDP组(15例)。对照组进行常规治疗;RM组在常规治疗基础上进行RM(PEEP递增法);EDP组在常规治疗基础上进行EDP治疗,于机械通气48 h后开始直至撤机;RM+EDP组在常规治疗基础上进行相同的RM及EDP治疗。比较各组氧合指数、肺超声评分(LUS)、膈肌移动度(DE)、膈肌增厚分数(DTF)、机械通气时间、ICU住院时间、28 d死亡率。结果(1)与对照组相比,RM组、RM+EDP组氧合指数在第3天、第7天明显增加(均P<0.05);与RM+EDP组相比,EDP组氧合指数在第3天、第7天明显降低(均P<0.05),RM组第7天氧合指数明显降低(P<0.05)。(2)与对照组相比,RM组、EDP组、RM+EDP组机械通气时间及ICU住院时间明显缩短(均P<0.05);与RM+EDP组相比,RM组、EDP组机械通气时间及ICU住院时间明显延长(均P<0.05)。(3)4组患者28 d死亡率差异无统计学意义(P>0.05)。(4)与对照组相比,RM组、RM+EDP组肺超声评分在第3天、第7天及撤机时明显降低(均P<0.05),EDP组肺超声评分撤机时明显降低(P<0.05);与RM+EDP组相比,EDP组肺超声评分在第3天、第7天及撤机时明显升高(均P<0.05),RM组撤机时明显升高(P<0.01)。(5)与对照组相比,EDP组、RM+EDP组膈肌移动度及膈肌增厚分数在第3天、第7天及撤机时明显增加(均P<0.05);与RM组相比,EDP组、RM+EDP组膈肌移动度及膈肌增厚分数在第3天、第7天及撤机时明显增加(均P<0.05)。结论RM或早期EDP能改善中重度ARDS患者氧合,缩短机械通气时间及ICU住院时间,且两者联合使用效果更显著,其机制至少部分与改善肺通气、保护膈肌功能相关。

Objective To investigate the effect of recruitment maneuver combined with early external diaphragm pacing on patients with moderate to severe ARDS.Methods Total 57 patients with moderate to severe ARDS who were treated in the emergency intensive care unit of our hospital from January 2022 to September 2023 were selected.According to the random number table method,they were divided into control group(14 cases),RM group(14 cases),EDP group(14 cases)and RM+EDP group(15 cases).Patients in control group received routine treatment,patients in RM group were treated with recruitment maneuver on the basis of routine treatment(PEEP increasing method).Patients in EDP group were treated with external diaphragm pacing on the basis of conventional treatment,from 48 hours after mechanical ventilation until weaning.Patients in RM+EDP group were treated with the same recruitment maneuver and external diaphragm pacing on the basis of routine treatment.The oxygenation index,lung ultrasound score(LUS),diaphragm excursion(DE),diaphragm thickening fraction(DTF),mechanical ventilation time,length of ICU stay and 28-day mortality were compared among groups.Results①Compared with control group,oxygenation index of RM group and RM+EDP group increased significantly on the 3rd and 7th day(all P<0.05).Compared with RM+EDP group,oxygenation index of EDP group was significantly decreased on the 3rd and 7th day(all P<0.05),and oxygenation index of RM group was significantly decreased on the 7th day(P<0.05).②Compared with control group,the mechanical ventilation time and length of ICU stay of RM group,EDP group and RM+EDP group were significantly shorter(all P<0.05).Compared with RM+EDP group,the mechanical ventilation time and length of ICU stay in RM group and EDP group were significantly prolonged(all P<0.05).③There was no significant difference in 28-day mortality among four groups(P>0.05).④Compared with control group,lung ultrasound scores of RM group and RM+EDP group were significantly lower on the 3rd day,the 7th day and the weaning time(all P<0.05),and the lung ultrasound scores of EDP group were significantly lower on the weaning time(P<0.05).Compared with RM+EDP group,lung ultrasound score of EDP group was significantly higher on the 3rd,7th day and at the weaning time(all P<0.05),and RM group was significantly higher at the weaning time(P<0.01).⑤Compared with control group,diaphragm excursion(DE)and diaphragmatic thickening fraction(DTF)of EDP group and RM+EDP group were significantly increased on the 3rd day,the 7th day and the weaning time(P<0.05).Compared with RM group,the diaphragm excursion(DE)and diaphragm thickening fraction(DTF)of the EDP group and RM+EDP group were significantly increased on the 3rd,7th and weaning time(all P<0.05).Conclusion Recruitment maneuver or early external diaphragm pacing could improve oxygenation,shorten mechanical ventilation time and length of ICU stay in patients with moderate to severe ARDS.The combination of the two would be more effective.The mechanism would be at least partly related to improving lung ventilation and protecting diaphragm function.