从PiCCO监测指标分析急性呼吸窘迫综合征患者撤机失败的因素  

Study on factors influencing the failure of PiCCO on weaning from mechanical ventilation in ARDS patients

作　　者：方明[1] 胡北[1] 陈淼[1] 江稳强[1] 柳学[1] 邓医宇[1] 黄伟平[1] 龙怡[1] 蒋文新[1] 曾红科[1] 

机构地区：[1]广东省人民医院(广东省医学科学院)急危重症医学部,广州510080

出　　处：《中华急诊医学杂志》2013年第7期765-769,共5页Chinese Journal of Emergency Medicine

基　　金：广东省科技计划项目（20108031600110）;广东省医学科研基金项目（C2011016）

摘　　要：目的探讨急性呼吸窘迫综合征（ARDS）患者撤机后血管外肺水、容量指标、心排指标的变化及其对撤机结局的影响。方法ARDS患者达到撤机条件后，序贯进行撤机、拔管，根据48h内撤机结局分为撤机成功组和失败组。在脉搏指数连续心输出量监测（PiCCO）下，观察比较撤机前（rIU）、撤机后1／2h（T1）、拔管后1／2h（他）和观察终点（撤机成功组为撤机后48h，失败组为重新上机前；T3）两组的血管外肺水指数（EVLWI）、胸腔内血容量指数（ITBI）、全心舒张末容积指数（GEDI）和心排量（CO）、心指数（CI）的前后变化，比较组间不同时间点的上述各参数的变化。结果纳入2010年8月至2012年9月共69例ARDS病例。不同时间点自身前后比较：GEDI和ITBI在T1、T2上升，EVLWI在T1、T2、T3均上升，PVPI在T3出现升高（均P〈0．05）。组间比较：在T1、T2、T3，失败组GEDI和ITBI均高于成功组（均P〈0．05），EVLWI在T2、乃显著高于成功组（均P〈0．05），PVPI在耶高于成功组（均P〈0．05）。结论ARDS患者呼吸机撤离、拔管等干预会带来额外容量负荷，并可能以渗透性血管外肺水增加的形式发生肺水肿，导致撤机失败；对EVLWI及容量指标的监测可能有助于对撤机结局的预测。Objective To analyze and evaluate the variability and effects of extra - vascular lung water index （EVLWI） , preload and cardiac function on weaning from mechanical ventilation in patients with ARDS. Methods All patients suffered from ARDS were treated with mechanical ventilation and monitored by pulse indicator continuous cardiac output （PiCCO） till they reached weaning criteria, then spontaneous breathing trial, weaning and extubation were performed in succession. The enrolled patients were divided into two groups, namely success group and failure group according to clinic outcome after weaning in 48 hours. EVLWI, preload markers such as global end-diastolic volume index （ GEDI ） , intrathoracic blood volume index （ITBI） , and cardiac function such as cardiac output and cardiac index were compared between two groups before weaning （ TO ）, 0. 5 h after weaning （ T1 ）, 0. 5 h after extubation （T2） , and observational endpoints （ T3 ） （ Observational endpoint is defined as ＂ before re-intubation＂ in failure group or 48 h after extubation in success group）. Results A total of 69 ARDS patients were enrolled from August 2010 to September 2012. Compared with variables before weaning, GEDI and ITBI were markedly higher observed at T1 and T2 （ P 〈 0.05 ）. EVLWI was significantly increased at T1, T2 and T3 （P 〈0. 01 ）. Increased pulmonary vascular permeability index （PVPI） were also found at T3 （P 〈0.05 ）. Compared with the success group, GEDI and ITBI in the failure group were higher at T1, T2 and T3 （ P 〈 0. 05 ）, and EVLWI were significant higher at T2 and 33 （ P 〈 0.05 ）, and increased PVPI at T3 （ P 〈 0.05）. Conclusions Additional volume load may resuh from weaning off mechanical ventilation and extubation in ARDS patients, and can induce high pulmonary vascular permeability causing pulmonary edema and weaning failure. Therefore, monitoring of EVLWI and preload markers could be valuable to predicting the prognosis of weaning from mechani

关 键 词：急性呼吸窘迫综合征 机械通气 脉搏指数连续心输出量监测 血管外肺水 

分 类 号：R563.8[医药卫生—呼吸系统]