肺牵张指数指导急性呼吸窘迫综合征最佳呼气末正压滴定的临床研究  

Clinical study of optimal positive end-expiratory pressure titration guided by lung stretch index in patients with acute respiratory distress syndrome

作　　者：胡凯 尹彩霞 熊旋 谢宇 李卜军 周立新[2] Hu Kai;Yin Caixia;Xiong Xuan;Xie Yu;Li Bujun;Zhou Lixin(Department of Critical Care Medicine,General Hospital of the Yangtze River Shipping,Wuhan 430010,Hubei,China;Department of Critical Care Medicine,Foshan First People's Hospital,Foshan 528000,Guangdong,China)

机构地区：[1]长江航运总医院重症医学科,湖北武汉430010 [2]佛山市第一人民医院重症医学科,广东佛山528000

出　　处：《中华危重病急救医学》2024年第2期142-146,共5页Chinese Critical Care Medicine

基　　金：广东省佛山市科技局立项课题(2020001001234)。

摘　　要：目的探讨急性呼吸窘迫综合征(ARDS)患者机械通气治疗时采用肺牵张指数(SI)滴定呼气末正压(PEEP)的临床实用性。方法采用平行随机对照试验,选取2022年8月至2023年2月长江航运总医院重症医学科接诊的需要机械通气的中、重度ARDS患者,并随机分为SI指导PEEP滴定组(SI组)和压力-容积曲线(P-V曲线)吸气支低位拐点(LIP)指导PEEP滴定组(LIP组)。所有患者入科后均采用仰卧位通气,并将床头抬高30°,积极治疗原发病,俯卧位通气12 h/d,采用控制性肺膨胀法进行肺复张等肺保护性通气策略,在此基础上,SI组以SI滴定机械通气参数;LIP组以P-V曲线吸气支LIP+2 cmH2O(1 cmH2O≈0.098 kPa)滴定机械通气参数。于复张前及治疗1、3、5 d监测氧合指数(PaO_(2)/FiO_(2))以及肺动态顺应性(Cdyn)、气道峰压(Pip)等呼吸力学指标。对比两组患者治疗效果。结果最终SI组41例,LIP组40例,两组患者性别、年龄、疾病类型等一般资料比较差异均无统计学意义。SI组机械通气时间(d:9.47±3.36比14.68±5.52)、重症监护病房(ICU)住院时间(d:22.27±4.68比27.57±9.52)均较LIP组明显缩短(均P<0.05)。SI组28 d病死率虽较LIP组降低,但差异无统计学意义〔19.5%(8/41)比35.0%(14/40),P>0.05〕。两组在复张前PaO_(2)/FiO_(2)及呼吸力学指标差异均无统计学意义。在治疗5 d时,SI组PaO_(2)/FiO_(2)较LIP组明显改善〔mmHg(1 mmHg≈0.133 kPa):225.57±47.85比198.32±31.59,P<0.05〕,Cdyn较LIP组明显升高(mL/cmH2O:47.39±6.71比35.88±5.35,P<0.01),Pip较LIP组明显降低(mmHg:35.85±5.77比43.87±6.68,P<0.05)。Kaplan-Meier生存曲线显示,两组28 d累积生存率差异无统计学意义(Log-Rank:χ^(2)=2.348,P=0.125)。结论应用SI滴定PEEP治疗ARDS患者可能改善预后。Objective To investigate the clinical practicability of positive end-expiratory pressure(PEEP)titrated by lung stretch index(SI)in patients with acute respiratory distress syndrome(ARDS).Methods A parallel randomized controlled trial was conducted.Patients with moderate to severe ARDS who required mechanical ventilation admitted to the department of critical care medicine of General Hospital of the Yangtze River Shipping from August 2022 to February 2023 were enrolled.They were randomly divide into SI guided PEEP titration group(SI group)and pressure-volume curve(P-V curve)inspiratory low inflection point(LIP)guided PEEP titration group(LIP group).All patients were ventilated in a supine position after admission,with the head of the bed raised by 30°.The primary disease was actively treated,prone position ventilation for 12 h/d,and lung protective ventilation strategies such as controlled lung expansion were used for lung recruitment.On this basis,mechanical ventilation parameters were titrated with SI in the SI group;the LIP group titrated mechanical ventilation parameters with P-V curve inspiratory LIP+2 cmH2O(1 cmH2O≈0.098 kPa).The oxygenation index(PaO_(2)/FiO_(2)),and respiratory mechanics indicators such as lung dynamic compliance(Cdyn),peak airway pressure(Pip)were monitored before recruitment maneuver and after 1,3,and 5 days of treatment.The therapeutic effect of the two groups was compared.Results There were 41 patients in the SI group and 40 patients in the LIP group.There was no significant difference in general information such as gender,age,and disease type between the two groups.The mechanical ventilation time and the length of intensive care unit(ICU)stay in the SI group were significantly shorter than those in the LIP group(days:9.47±3.36 vs.14.68±5.52,22.27±4.68 vs.27.57±9.52,both P<0.05).Although the 28-day mortality of the SI group was lower than that of the LIP group,the difference was not statistically significant[19.5%(8/41)vs.35.0%(14/40),P>0.05].On the fifth day,the PaO_(2)/FiO_(2)

关 键 词：肺牵张指数 压力-容积曲线 急性呼吸窘迫综合征 Kaplan-Meier曲线 

分 类 号：R563.8[医药卫生—呼吸系统]