气道压力释放通气应用于急性肺损伤／急性呼吸窘迫综合征患者的临床研究  

The clinical effect of airway pressure release ventilation for acute lung injury/acute respiratory distress syndrome

作　　者：宋邵华[1] 田惠玉[1] 杨秀芬[1] 胡振杰[2] 

机构地区：[1]河北医科大学第一医院重症医学科,河北石家庄050031 [2]河北医科大学第四医院重症医学科,河北石家庄050021

出　　处：《中华危重病急救医学》2016年第1期15-21,共7页Chinese Critical Care Medicine

基　　金：河北省医学科学研究重点课题（20110305）

摘　　要：目的评价气道压力释放通气（APRV）对急性肺损伤／急性呼吸窘迫综合征（ALI／ARDS）患者的疗效，同时评估呼吸机相关性肺损伤（VILI）程度，并探讨其可能的机制。方法采用前瞻性研究方法，选择2010年12月至2012年2月河北医科大学第一医院重症医学科收治的各种原因所致ALUARDS患者。按随机数字表法将患者分为两组：APRV组采用APRV模式；对照组采用小潮气量肺保护性通气策略，即同步间歇指令通气＋呼气末正压（SIMV＋PEEP）。所有患者均应用AVEA呼吸机行机械通气治疗，记录呼吸机设置参数及气道峰压（Ppeak）、平均气道压（Pmean），患者的脉搏血氧饱和度（SpO2）、平均动脉压（MAP）、心率（Hn）、中心静脉压（CVP）、动脉血气、尿量、镇静／肌松剂使用情况等。通过AVEA呼吸机“转折点（Pflex）操作”，采用低流速法描记肺准静态压力-容积曲线（P—V曲线），自动测量并计算高、低位拐点（UIP、UP）和三角区Pflex容积（Vdelta）。根据准静态P—V曲线结果设置呼吸机参数，通气24h后再次描记准静态P—V曲线。分别抽取患者入组时及通气24h和48h静脉血，采用酶联免疫吸附试验（ELISA）检测肺表面活性蛋白D（SP—D）、唾液酸化大分子黏蛋白（KL-6）水平，并采用多元logistic回归分析其对28d预后的预测价值。结果人选26例ALI／ARDS患者，其中22例完成试验，APRV组10例，对照组12例。两组患者人组时基线资料及准静态P—V曲线差异无统计学意义。两组患者通气24h和48h时氧合均明显改善，但血流动力学指标无明显变化；APRV组Pmean（cmH2O，1cmH2O=0．098kPa）明显高于对照组（24h为24．20±4．59比17．50±3．48，P〈0．01；48h为18．10±4．30比15．00±2．59，P〈0．05）。通气24h时，APRV组Vdelta增加的患者比例高于对照组（90％比75％），但差异无统计学意义（P〉0．05）。通Objective To evaluate the effect of airway pressure release ventilation （APRV） in patients with acute lung injury/acute respiratory distress syndrome （ALI/ARDS）, to evaluate the extent of ventilator-induced lung injury （VILI）, and to explore its possible mechanism. Methods A prospective study was conducted in the Departmentof Critical Care Medicine of the First Hospital of Hebei Medical University from December 2010 to February 2012. The patients with ALI/ARDS were enrolled. They were randomly divided into two groups. The patients in APRV group were given APRV pattern, while those in control group were given lung protection ventilation, synchronized intermittent mandatory ventilation with positive end-expiratory pressure （SIMV＋PEEP）. All patients were treated with AVEA ventilator. The parameters such as airway peak pressure （Ppeak）, mean airway pressure （Pmean）, pulse oxygen saturation （SpO2）, mean arterial pressure （MAP）, heart rate （HR）, central venous pressure （CVP）, arterial blood gas, urine output （UO）, the usage of sedation and muscle relaxation drugs were recorded. AVEA ventilator ＂turning point （Pflex） operation＂ was used to describe the quasi-static pressure volume curve （P-V curve）. High and low inflection point （UIP, LIP） and triangular Pflex volume （Vdelta） were automatically measured and calculated. The ventilation parameters were set, and the 24-hour P-V curve was recorded again in order to be compared with subsequent results. Venous blood was collected before treatment, 24 hours and 48 hours after ventilation to measure lung surfactant protein D （SP-D） and large molecular mucus in saliva （KL-6） by enzyme linked immunosorbent assay （ELISA）, and the correlation between the above two parameters and prognosis on 28 days was analyzed by muhinomial logistic regression. Results Twenty-six patients with ALI/ARDS were enrolled, and 22 of them completed the test with 10 in APRV group and 12 in control group. The basic parameters an

关 键 词：气道压力释放通气 氧合 呼吸机相关性肺损伤 

分 类 号：R563.8[医药卫生—呼吸系统]