床旁超声对机械通气患者呼气末正压诱导肺容积改变的评估价值  

Assessment of positive end-expiratory pressure induced lung volume change by ultrasound in mechanically ventilated patients

作　　者：沈鹏[1] 罗汝斌[2] 高玉芝[2] 王吉文[2] 张茂[2] 

机构地区：[1]浙江省嘉兴市第一医院重症医学科,314001 [2]浙江大学医学院附属第二医院急诊医学中心

出　　处：《中华结核和呼吸杂志》2014年第5期332-336,共5页Chinese Journal of Tuberculosis and Respiratory Diseases

摘　　要：目的探讨床旁超声在机械通气患者呼气末正压（PEEP）诱导肺容积改变的评估价值。方法选取2011年6月至2012年12月浙江大学医学院附属第二医院急诊监护室（EICU）内符合急性肺损伤（Au）或ARDS并接受机械通气的患者，采用TaemaXTEND系列呼吸机专利的压力容积曲线测定程序自动测定PEEP为12、8、4、0cmH2O（1cm H2O=0．098kPa）时的压力容积曲线，得到不同PEEP水平下的呼气末肺容积（EELV）并计算呼气末肺容积变化（AEELV），根据AEELV变化确定合适PEEP，在呼吸机测定压力容积曲线的同时使用床旁超声评估肺容积变化，计算肺部超声评分（LUS）及肺部超声评分变化（ALUS），相关计量数据进行t检验或单因素方差分析，将ALUS和AEELV进行Spearman相关性分析。结果共纳入18例接受机械通气的严重创伤患者，年龄23～79岁，平均（52±15）岁，肺损伤评分（LIS）平均为（2．1±0．5）分；根据压力容积曲线的测定结果将PEEP从（4．7±1．8）cmH2O调整到（7．6±1．5）cmH2O（t=9．006，P=0．000）后，患者的氧合指数（PO2／FiO2）从（208±33）mmHg（1mmHg=0．133kPa）升高到（274±51）mmHg（t=5．309，P=0．000）；随着PEEP水平的增加，肺超声评分也相应地从（31．4±4．5）分升高到（34．1±4．7）分（t=4．123，P=0．001）；PEEP为0、4、8、12cmH2O时，各PEEP水平之间ALUS与AEELV之间呈显著正相关（r=0．82，P〈0．01）。调整PEEP水平前后ALUS与氧合指数变化（△PO2／FiO2）之间呈显著正相关（r=0．66，P〈0．01）。测定PEEP为0、4、8、12cmH2O水平压力容积曲线时，患者平均动脉压、心率变化差异无统计学意义（均P〉0．05），未发生气胸等并发症。结论床旁肺部超声可以协助机械通气患者选择合适的PEEP水平，可作为传统PEEP调节依据的有益补充。Objective To investigate the value of lung ultrasound for assessing positive endexpiratory pressure （PEEP）-induced lung volume change in mechanically ventilated patients with acute lung injury（ALI） or acute respiratory distress syndrome （ARDS）. Methods Eighteen patients with ALI or ARDS were prospectively studied. P-V curves and lung ultrasound were performed at PEEP 12,8,4 and 0 cmH2O（1 cmH2O = 0. 098 kPa）. PEEP-induced lung volume change was measured using the P-V curve method and lung ultrasound. Results Four lung ultrasound entities were defined： consolidation, multiple irregularly spaced B lines, multiple abutting B lines and normal aeration. For each of the 12 lung regions examined, PEEP-induced ultrasound changes were measured and an lung ultrasound score （LUS）was calculated. A highly significant correlation was found between PEEP-induced lung volume change measured by P-V curves and LUS change （ r = 0. 82, P 〈 0. 01 ）. A statistically significant correlation was found between LUS change and PEEP-induced increase in PaO2 （r = 0. 66, P 〈 0. 01 ）. Conclusion PEEP- induced lung volume change can be adequately estimated with bedside lung ultrasound. Since lung ultrasound cannot assess PEEP-induced lung hyperinflation, it should not be the sole method for PEEP titration.

关 键 词：超声检查 正压呼吸 呼吸 人工 

分 类 号：R563.8[医药卫生—呼吸系统]