俯卧位通气联合肺复张对重度急性呼吸窘迫综合征患者预后的影响  

The effects of prone position ventilation combined with recruitment maneuvers on outcomes in patients with severe acute respiratory distress syndrome

作　　者：周翔[1] 刘大为[1] 隆云[1] 张青[1] 崔娜[1] 何怀武[1] 赵华[1] 刘晔[1] 丁欣[1] 杜倩[1] 张斌[1] 陈焕[1] 

机构地区：[1]中国医学科学院北京协和医学院北京协和转化医学中心北京协和医院重症医学科,100730

出　　处：《中华内科杂志》2014年第6期437-441,共5页Chinese Journal of Internal Medicine

基　　金：卫生公益性行业科研专项经费项目（201202011）

摘　　要：目的 探讨俯卧位通气联合肺复张对重度急性呼吸窘迫综合征（ARDS）患者预后的影响.方法 依据ARDS“柏林标准”将入选的重度ARDS患者随机分为标准通气组和早期俯卧位通气联合肺复张组（简称联合通气组）.标准通气组采用保护性机械通气策略,联合通气组在保护性机械通气策略的基础上采用俯卧位通气联合肺复张的方法进行机械通气.观察2组患者氧合指数、气道平台压、静态肺顺应性、28 d病死率、ICU留治时间、机械通气时间、气管切开率、人工气道拔除时间、气胸和压疮发生率.结果 （1）共入选重度ARDS患者116例,标准通气组60例,联合通气组56例,2组基线资料差异无统计学意义（P值均＞0.05）.（2）早期俯卧位通气联合肺复张后,联合通气组氧合指数[（176-24）mmHg（1 mmHg =0.133 kPa）]高于标准通气组[（138±37） mmHg;P ＜0.01],呼气末正压（PEEP）水平[（8±2）cmH2O（1 cmH2O=0.098 kPa）比（10±2）cmH2O;P=0.001]、吸入氧浓度（FiO2）[（0.50±0.12）％比（0.60±0.10）％]低于标准通气组（P＜0.01）,而气道平台压、静态肺顺应性2组间无差别.（3）与标准通气组比,联合通气组ICU留治时间[（22±19）d比（26±22）d]、机械通气时间缩短[（13±6）d比（19±7）d;P值均＜0.05],28 d病死率下降（16.1％比33.3％;P＜0.05）,气管切开率、人工气道拔除时间2组间无差异.（4）Ⅰ级压疮发生率联合通气组（53.6％）高于标准通气组（10.0％;P＜0.01）,气胸发生率、Ⅱ级压疮发生率2组间无差异,2组均未发生Ⅲ级或Ⅳ级压疮.结论 早期俯卧位通气联合肺复张能改善重度ARDS患者氧合及预后,且不增加严重并发症的发生率.Objective To evaluate the effects of prone position ventilation combined with recruitment maneuvers（RM） on clinical outcomes in patients with severe acute respiratory distress syndrome （ARDS）.Methods In this prospective,randomized,controlled trial,we randomly assigned 116 sequential patients with severe ARDS to the intervention group （which undergo prone-positioning with RM sessions of at least 10 hours） or to the control group （which be left in the supine position）.Results From July 2012 to July 2013,116 severe ARDS patients sequentially admitted to the critical department of Peking Union Medical College Hospital were enrolled in the study with 60 patients assigned to the control group and 56 patients to the intervention group.No significant difference was found between the two groups in the demographics including the median patient age,sex ratio,initial Acute Physiology and Chronic Health Evaluation Ⅱ scores,initial pulmonary function and the sources of ARDS.The oxygenation index recorded in the supine position was significantly higher in the intervention group than in the control group since day 3,whereas the positive end-expiratory pressure and fraction of inspired O2 were significantly lower in the intervention group.The plateau pressure and static compliance of the respiratory system were similar in the two groups.The intervention group had shorter length of ICU stay,fewer ventilation days and decreased 28-day mortality than the control group.The tracheotomy ratio and the time to successful extubation were similar in the two groups.No significant difference between the two groups was shown in the incidence of complications,except for the grade 1 pressure sore,which was higher in the intervention group.Conclusions In patients with severe ARDS,application of prolonged prone-positioning with RM sessions significantly improves the clinical outcomes.

关 键 词：呼吸窘迫综合征 成人 俯卧位 通气机 机械 肺复张 

分 类 号：R563.8[医药卫生—呼吸系统]