食管压法设置呼气末正压对急性呼吸窘迫综合征模型猪血流动力学及气体交换的影响  

Effect of positive end expiratory pressure guided by esophageal pressure on hemodynamic and gas exchange in pig model with acute respiratory distress syndrome

作　　者：张敏[1,2] 颜培夏 吴晓燕 郑瑞强 

机构地区：[1]苏北人民医院重症医学科,江苏扬州225001 [2]张家港市第一人民医院重症医学科,江苏省215600

出　　处：《中华临床医师杂志（电子版）》2016年第5期663-668,共6页Chinese Journal of Clinicians(Electronic Edition)

基　　金：江苏省"333高层次人才培养工程"基金(2011-15);扬州市科技攻关-社会发展科技攻关(2012133)

摘　　要：目的观察食管压法设置最佳呼气末正压（PEEP）与最佳氧合法相比对急性呼吸窘迫综合征（ARDS）模型猪血流动力学及气体交换的影响。方法 12只普通家猪随机分为食管压组和最佳氧合组,两组均给予气管插管接呼吸机辅助通气、留置股动脉导管接PiCCO仪监测血流动力学、留置右颈内静脉导管测中心静脉压（CVP）,并于术后稳定30 min后,行生理盐水肺泡灌洗复制猪ARDS模型。模型成功后,在充分肺复张的基础上,两组分别使用食管压法和最佳氧合法设置最佳PEEP,并以此维持通气4 h。观察并记录基础状态（PEEP 5 cm H2O）（Tbase）、ARDS模型稳定（PEEP 5 cm H2O）（T0）和最佳PEEP维持机械通气4 h期间（T1~T4）的血流动力学及气体交换的变化。结果以最佳PEEP通气4 h期间,食管压组选择PEEP值明显低于最佳氧合组（P〈0.05）。血流动力学方面：与成模时比较,食管压和最佳氧合组以最佳PEEP通气4 h期间,心率（HR）、平均动脉压（MAP）、CVP、心输出量指数（CI）、每搏指数（SVI）、全身血管阻力指数（SVRI）、左心室收缩力指数（dPmax）、全心舒张容积指数（GEDI）、胸腔内血容量（ITBI）变化均无统计学差异（P〉0.05）,且两组间各时间点血流动力学指标比较无统计学差异（P〉0.05）。气体交换方面：与成模时比较,食管压组和最佳氧合组以最佳PEEP通气4 h期间氧合指数（PaO2/FiO2）、动脉血氧饱和度（SaO2）、氧输送（DO2）均明显上升（P〈0.05）,肺内分流（Qs/Qt）明显下降（P〈0.05）,但组间无统计学差异（P〉0.05）;两组以最佳PEEP通气第2小时开始乳酸（Lac）水平均较成模时明显下降（P〈0.05）,但组间无统计学差异（P〉0.05）;两组以最佳PEEP通气期间动脉血pH（p Ha）较成模时有所上升,但无统计学意义（P〉0.05）;最佳氧合组以最佳PEEP通气1、2、3 h期间PaCO2较前成模时明显下降（P〈Objective To observe the effect of PEEP guided by esophageal pressure compared with the optimal oxygenation-directed PEEP on hemodynamic and gas exchange in pigs with acute respiratory distress syndrome. Methods 12 ordinary pigs were randomly divided into esophageal pressure group and the optimal oxygenation group, the two groups were given tracheal intubation, mechanical ventilated, PiCCO hemodynamics monitored and right internal jugular vein catheter to test CVP, stable after the operation for 30 minutes, all animals were given lung lavage with normal saline to induce ARDS pigs. The optimal PEEP were set by esophageal pressure titration or optimal oxygenation after lung recruitment, thereafter, ventilation continued for 4 h. Hemodynamics, gas exchange were recorded before saline lung lavage （PEEP 5 cmH2O） （Tbase）, after stabilization of ARDS model （PEEP 5 cmH2O） （T0） and after using optimal PEEP for 0, l, 2, 3 and 4 h （T1-T4）. Results The level of PEEP in esophageal pressure group was significantly lower than that in the optimal oxygenation group （P〈0.05）. In terms of hemodynamics, compared with ARDS model, during mechanical ventilation set by optimal PEEP in two groups, the changes of heart rate （HR）, mean artery pressure （MAP）, central venous pressure （CVP）, cardiac Index （CI）, stroke volume index （SVI）, systemic vascular resistance index （SVRI）, index of left ventricular contractility （dPmax）, global end diastolic volume index （GEDI） and intrathoracic blood volume index （ITBI） showed no significant difference as well as the changes between the two groups （P〉0.05）. In terms of gas exchanges, the oxygenation index （PaO2/FiO2）, arterial oxygen saturation （SaO2） and oxygen delivery （DO2） were significantly higher while the intrapulmonary shunt fraction （Qs/Qt） were significantly lower than that in ARDS model （P〈0.05）, but the arterial pH （pHa） showed no significant difference （P〉0.05）. After using optimal PEEP for

关 键 词：急性呼吸窘迫综合征 机械通气 血流动力学 氧合 

分 类 号：R563.8[医药卫生—呼吸系统]