跨肺压滴定PEEP在急性主动脉夹层术后低氧血症患者中的临床应用研究  

Clinical application of transpulmonary gradient titration PEEP in patients with hypoxemia after acute aortic dissection surgery

作　　者：赵谊[1] 章文豪[1] 穆心苇[1] 章淬[1] 孙芳[1] 祁祥[1] 邹磊[1] 

机构地区：[1]南京医科大学附属南京医院南京市第一医院重症医学科,江苏南京210006

出　　处：《实用临床医药杂志》2016年第24期1-6,共6页Journal of Clinical Medicine in Practice

基　　金：江苏省南京市医学重点科技发展项目(ZKX14036)

摘　　要：目的探讨跨肺压指导呼气末正压通气(PEEP)选择对急性主动脉夹层术后低氧血症患者氧合、血流动力学及预后的影响。方法采用前瞻性随机对照研究,入选2014年1月—2015年8月急性Stanford A型主动脉夹层术后低氧血症患者28例,随机分为2组:个体化治疗组(n=19),肺复张后通过食道压监测结果调整PEEP;传统机械通气治疗组(n=9),肺复张后按照ARDSnet建议调整PEEP。比较2组患者呼吸、血流动力学参数、机械通气时间、住ICU时间及住院病死率。结果第72 h,个体化治疗组的PEEP、吸气末跨肺压均较传统机械通气治疗组高(P<0.05);第72 h,个体化治疗组动脉血氧分压(PO2)、氧合指数高于传统机械通气治疗组(P<0.05)。整个实验过程中,2组患者的心率和心排量无明显差异(P>0.05)。个体化治疗组患者机械通气时间和住ICU时间均比传统机械通气组时间短(P<0.05),2组患者的住院病死率无统计学差异(P>0.05)。结论肺复张后应用跨肺压指导PEEP的机械通气策略可改善急性主动脉夹层术后低氧血症患者氧合,缩短机械通气时间、住ICU时间,且不会引起循环波动。Objective To explore the influence of transpulmonary gradient titration positive end expiratory pressure （PEEP） selection on oxygenation, hemodynamies and prognosis of patients with hypoxemia after acute aortic dissection surgery. Methods A perspective, randomized and con- trolled study was conducted, in which 28 patients with hypoxemia after acute type Stanford A aortic dissection surgery in our hospital from January 2014 to August 2015 were enrolled and randomly divid- ed into two groups. Individual treatment group （n = 19） received regulation of PEEP by esophageal pressure monitoring results after pulmonary re-expansion, while conventional mechanical ventilation treatment group （ n = 9） was given regulation of PEEP according to ARDSnet advice after pulmonary re-expansion. Respiration, hemodynamic parameters, mechanical ventilation duration, intensive care unit （ICU） stays and hospital mortality rate were compared between two groups. Results At 72 h after treatment, individual treatment group was markedly higher than conventional mechanical ventilation treatment group in PEEP and end-inspiratory transpulmonary gradient （P 〈 0.05 ）, and was notably higher in arterial partial pressure of oxygen （ PO2 ） and oxygenation indexes （P 〈 0.05 ）. During the whole experiment , there was no significant difference between two groups in heart rate and cardiac output （P 〉 0.05）. Meanwhile, individual treatment group was evidently shorter than control group in mechanical ventilation duration and ICU stay （P 〈 0.05 ）. However, there was no significant difference between two groups in hospital mortality rate （P 〉 0.05 ）. Conclusion Application of mechanical ventilation using transpulmonary gradient-guided PEEP after pulmonary re-expansion can effectively improve the oxygenation and shorten the mechanical ventilation and ICU stay without triggering circular fluctuation in patients with hypoxemia after acute aortic dissection surgery.

关 键 词：急性主动脉夹层 低氧血症 跨肺压 食道压 

分 类 号：R543.1[医药卫生—心血管疾病]