摘要
目的探讨床旁肺部超声与肺牵张指数在急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)患者肺复张中对最佳呼气末正压(positive end-expiratory pressure,PEEP)的导向价值。方法选取2021年2月—2023年10月在郑州大学第二附院重症医学科(intensive care unit,ICU)需要有创机械通气的ARDS患者90例,根据肺复张后PEEP设置方法将患者随机分为超声组(45例)和牵张组(45例)。两组均采用PEEP递增法进行肺复张,肺复张后超声组采用床旁超声导向法设置PEEP,牵张组采用肺牵张指数法设置PEEP。监测两组患者肺复张前、肺复张后15 min、1 h、6 h、24 h的氧合指数(PaO2/FiO2)、动态顺应性(dynamic compliance,Cdyn)、平均气道压、气道峰压的动态变化;监测两组患者肺复张前、肺复张后24 h心率、平均动脉压和中心静脉压水平;探求两组最佳PEEP值及对应的复张末容积;记录两组患者机械通气时间、ICU住院时间、气压伤发生率、肺外器官功能衰竭发生率及28天病死率。结果肺复张后,超声组患者的氧合指数、Cdyn、平均气道压、气道峰压在复张后15 min、1 h、6 h、24 h均高于牵张组(均P<0.05);肺复张后24 h,两组患者的心率、平均动脉压、中心静脉压差异均无统计学意义(均P>0.05)。肺复张后,超声组患者滴定的最佳PEEP值及对应的复张末容积均大于牵张组(均P<0.05),超声组患者的机械通气时间、ICU停留时间短于牵张组(均P<0.05)。两组患者的气压伤发生率、肺外器官功能衰竭率、28天病死率差异无统计学意义(均P>0.05)。结论床旁肺部超声与肺牵张指数导向的PEEP均可改善氧合和呼吸系统顺应性,对血流动力学无不良影响,而床旁肺部超声导向的PEEP更能使肺泡充分膨胀,更有利于改善患者的氧合和呼吸系统顺应性,导向价值高于肺牵张指数。
Objective To investigate the guiding value of bedside lung ultrasound and lung stretch index for optimal positive end-expiratory pressure(PEEP)in lung recruitment of patients with acute respiratory distress syndrome(ARDS).Methods From February 2020 to October 2023,90 patients with ARDS requiring invasive mechanical ventilation were selected from the Department of Critical Care Medicine,the Second Affiliated Hospital of Zhengzhou University.According to the setting method of PEEP after lung recruitment,they were randomly divided into an ultrasound group(45 cases)and a stretch group(45 cases).Both groups were treated with PEEP incremental method for lung recruitment,and the ultrasound group was treated with bedside ultrasound-guided method to set PEEP after lung recruitment.PEEP was set by lung stretch index method in the stretch group.The dynamic changes of oxygenation index(PaO2/FiO2),dynamic compliance(Cdyn),mean airway pressure and peak airway pressure were monitored before lung recruitment and 15 min,1 h,6 h and 24 h after lung recruitment.Heart rate,mean arterial pressure and central venous pressure were monitored before and 24 h after lung recruitment in the two groups.The optimal PEEP value and the corresponding volume at the end of recruitment were explored.The mechanical ventilation time,ICU hospitalization time,incidence of barotrauma,incidence of extrapulmonary organ failure,and 28-day mortality were recorded as well.Results After lung recruitment,the oxygenation index,Cdyn,mean airway pressure,and peak airway pressure in the ultrasound group were higher than those in the stretch group at 15 min,1 h,6 h,and 24 h after recruitment(all P<0.05).There was no significant difference in heart rate,mean arterial pressure or central venous pressure between the two groups at 24 h after lung recruitment(all P>0.05).After lung recruitment,the optimal PEEP value and the corresponding volume at the end of recruitment in the ultrasound group were higher than those in the distraction group(both P<0.05).The mechanical ventilation time and ICU stay in the ultrasound group were shorter than those in the stretch group(both P<0.05).There was no significant difference in the incidence of barotrauma,extrapulmonary organ failure rate or 28-day mortality between the two groups(all P>0.05).Conclusions Both bedside lung ultrasound-guided PEEP and lung stretch index-guided PEEP can improve oxygenation and respiratory compliance,and have no adverse effects on hemodynamics.Bedside lung ultrasound-guided PEEP can make the alveoli fully expand,which is more conducive to improving patients’oxygenation and respiratory compliance,and the guiding value is higher than the lung stretch index.
作者
刘晓静
王文涛
李家琛
郑乃升
LIU Xiaojing;WANG Wentao;LI Jiachen;ZHENG Naisheng(Department of Critical Care Medicine,Second Affiliated Hospital of Zhengzhou University,Zhengzhou,Henan 450003,P.R.China)
出处
《中国呼吸与危重监护杂志》
CAS
CSCD
2024年第7期470-477,共8页
Chinese Journal of Respiratory and Critical Care Medicine
基金
河南省医学科技攻关计划联合共建立项项目(LHGJ20200419)
关键词
急性呼吸窘迫综合征
肺复张
呼气末正压
床旁肺部超声
肺牵张指数
Acute respiratory distress syndrome
lung recruitment
positive end-expiratory pressure
bedside lung ultrasound
pulmonary stretch index
