侧卧位通气治疗肺内/外源性ARDS的对比观察
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摘要
目的：比较观察侧卧位通气对肺内外源性急性呼吸窘迫综合征(ARDS)患者的疗效及预后。方法：对23例收治ICU的ARDS患者按发病原因分为肺内源性组(ARDSp)及肺外源性组(ARDSexp)。两组均实行侧卧位通气治疗,依次行仰卧位、侧卧位、仰卧位通气各1h。各体位通气结束时记录患者功能残气量(FRC)、气道峰压(PIP)、气道平台压(Pplat)、静态肺顺应性(Cst)、气道阻力(Raw)、平均血压(MAP)、心率(HR)、心脏指数(CI)等指标,并行血气分析记录动脉血氧分压(PaO2)、氧合指数(PaO2/FiO2)、动脉二氧化碳分压(PaCO2)。结果：(1)侧卧位后两组患者的动脉血氧分压(Pa02)、氧合指数(PaO2/FiO2)侧卧位后增加有统计学意义(P<0.05),恢复仰卧位后继续增加(P<0.05)并较初始仰卧位明显增加(P<0.01)；肺外源性组氧合改善明显好于肺内源性ARDS组患者,且两组之间有统计学意义(P<0.05)。以PaO2升高10mmHg为治疗有效标准,治疗有效率肺外源性组为72%,肺内源性组为33%,两组比较差异有显着性。(2)功能残气量的变化：FRC侧卧位后的增加有统计学意义(P<0.05),恢复仰卧位后下降也有统计学意义(P<0.05),而恢复仰卧位后与初始仰卧位相比无显着差异(P>0.05)。肺内源性组比肺外源性组改善更明显,有统计学意义(P<0.05)。(3)肺呼吸力学的变化：两组患者体位改变后PIP、Pplat、Cst、Raw等指标变化均无统计学意义(P均>0.05)。(4)血流动力学的变化：两组患者体位改变后HR、CI和M AP变化均无统计学意义(P>0.05)。结论：无论是肺内源性ARDS组还是肺外源性ARDS组,侧卧位通气后可明显增加FRC并改善氧合；但其对预后的影响尚需进一步研究。
Objective:To assess the effects of lateral position ventilation for treatment of acute respiratory distress syndrome (ARDS) originating from pulmonary disease and extra-pulmonary disease. Methods:Twenty-three patients with ARDS were divided into pulmonary disease group and extra-pulmonary disease group. All patients were mechanically ventilated Supine position, lateral position and supine position were successively adopted in each patient and each position continued for 1 h. Functional residual capacity (FRC), peak inspiratory pressure (PIP), plateau airway pressure (Pplat), airway resistance (Raw), static pulmonary compliance (Cst), heart rate (HR), cardiac index (CI),mean artery pressure (MAP) and arterial blood gas were measured at the end of each epoch. Results:(1) The change of gas exchanges:When patients were turned to lateral position, Arterial oxygenation index (PaO2/FiO2) and partial pressure of arterial oxygen (PaO2) increased (P<0.05) and increased after resumed supine ventilation (P<0.05). Compared with initial supine ventilation, PaO2/FiO2 and PaO2 increased greatly after resumed supine ventilation (P<0.01). PaO2 was increased in extra-pulmonary disease group compared with pulmonary disease group at the same time. If a 10 mmHg increase was regarded as the standard of treatment effectiveness, then the effective rate in the extra-pulmonary disease group was 72% and in the pulmonary disease group was 33%, the difference being significant (P<0.05). (2) The change of lung volume:FRC increased after lateral ventilation (P<0.05) and decreased after resumed supine ventilation (P< 0.05). Compared with initial supine ventilation, there was no significant difference in FRC after resumed supine ventilation (P>0.05). FRC was increased in pulmonary disease group compared with extra-pulmonary disease group, the difference being significant (P <0.05). (3) The change of lung mechanics:There were no significant differences in PIP, Pm, Raw, Cst after change of positions (P>0.05 for all). (4) The change of hemodynamics: There were no significant differences in HR and MAP after change of positions (P>0.05 for all). Conclusion:Increased FRC and improved oxygenation markedly in lateral position ventilation in two groups; the outcome of the patients with ARDS needs further investigation.
Objective:To assess the effects of lateral position ventilation for treatment of acute respiratory distress syndrome (ARDS) originating from pulmonary disease and extra-pulmonary disease. Methods:Twenty-three patients with ARDS were divided into pulmonary disease group and extra-pulmonary disease group. All patients were mechanically ventilated Supine position, lateral position and supine position were successively adopted in each patient and each position continued for 1 h. Functional residual capacity (FRC), peak inspiratory pressure (PIP), plateau airway pressure (Pplat), airway resistance (Raw), static pulmonary compliance (Cst), heart rate (HR), cardiac index (CI),mean artery pressure (MAP) and arterial blood gas were measured at the end of each epoch. Results:(1) The change of gas exchanges:When patients were turned to lateral position, Arterial oxygenation index (PaO2/FiO2) and partial pressure of arterial oxygen (PaO2) increased (P<0.05) and increased after resumed supine ventilation (P<0.05). Compared with initial supine ventilation, PaO2/FiO2 and PaO2 increased greatly after resumed supine ventilation (P<0.01). PaO2 was increased in extra-pulmonary disease group compared with pulmonary disease group at the same time. If a 10 mmHg increase was regarded as the standard of treatment effectiveness, then the effective rate in the extra-pulmonary disease group was 72% and in the pulmonary disease group was 33%, the difference being significant (P<0.05). (2) The change of lung volume:FRC increased after lateral ventilation (P<0.05) and decreased after resumed supine ventilation (P< 0.05). Compared with initial supine ventilation, there was no significant difference in FRC after resumed supine ventilation (P>0.05). FRC was increased in pulmonary disease group compared with extra-pulmonary disease group, the difference being significant (P <0.05). (3) The change of lung mechanics:There were no significant differences in PIP, Pm, Raw, Cst after change of positions (P>0.05 for all). (4) The change of hemodynamics: There were no significant differences in HR and MAP after change of positions (P>0.05 for all). Conclusion:Increased FRC and improved oxygenation markedly in lateral position ventilation in two groups; the outcome of the patients with ARDS needs further investigation.
引文
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[1]中华医学会重症医学分会.急性肺损伤/急性呼吸窘迫综合征诊断和治疗指南(2006)[J].中国危重病急救医学,2006,18(12)：706-710.
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[10]Rialp G, Betbese AJ, Perez-Marquez M, et al. Short-term-effects of inhaled nitric oxide and prone position in pulmonary and extra-pulmonary acute respiratory distress syndrome[J]. Am J Respir Crit Care Med,2001,164(2):243-249.
[11]Cohen ES, Elpern E, Silver MR. Puimonary alveolar proteinosis causing severe hypoxemic respiratory failure treated with sequential whole-lung lavage utilizing venovenous extracorporeal membrane oxygenation:a case report and review[J].Chest,2001(120):1024-1026.
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[14]Hirche TO,Crouch EC, Espinola M,et al.Neutrophil serine proteinases inactivate surfactant protein D by cleaving within a conserved subregion of the carbohydrate recognition recognition domain[J]. Biol Chem,2004,279(26):27688—27698.
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[16]Swystun V, Chen L, Factor P, el al.Apical trypsin increases ion transport and resistance by a pho-spholipase C--dependent rise of Ca2+[J]. Physiol Lung Cell Mol Physiol,2005,288(5):820-830
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[22]Guerin C, Gaillard S, Lemasson S; et al. Effects of systematic prone positioning in hypoxemic acute respiratory failure:a randomized controlled trial[J]. JAMA. 2004;292(19):2379-2387.
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[30]Fernandez R, Trenchs X, Klamburg J, et al. Prone positioning in acute respiratory distress syndrome:a multicenter randomized clinical trial[J]. Intensive Care Med. 2008 Aug;34(8):1487-1491.
[31]Gattinoni L, Carlesso E, Taccone P, et al.Prone positioning improves survival in severe ARDS:a pathophysiologic review and individual patient meta-analysis[J].. Minerva Anestesiol.2010 Jun;76(6):448-454.
[32]Pipeling MR, Fan E. Therapies for refractory hypoxemia in acute respiratory distress syndrome[J].JAMA.2010 Dec 8;304(22):2521-2527.
[33]Fessler HE, Talmor DS. Should prone positioning be routinely used for lung protection during mechanical ventilation? [J].Respir Care.2010 Jan;55(1):88-99.
[2]Ashbaugh DG, Bigelkow DB, Petty TL, et al. Acute respiratory distress in adults[J]. Lancet,1967,2(7511):319-323.
[3]Bernard GR, Artigas A, Brigham KL, et al. The American-European Consensus Conference on ARDS:definitions, mechanisms, relevant outcomes, and clinical trial coordination[J]. Am J Respir Crit Care Med,1994,149(3 Pt 1):818-824.
[4]中华医学会呼吸病学分会.急性肺损伤/急性呼吸窘迫综合征的诊断标准(草案)[J]．中华结核和呼吸杂志,2000,23(4)：203.
[5]Piehl MA, Brown RS. Use of extreme position changes in respiratory failure[J]. Crit Care Med,1976,4(1):13-14.
[6]吴威士,罗敏,杨翠华.急性肺损伤/急性呼吸窘迫综合征患者侧卧位通气与俯卧位通气的对比观察[J].中华结核和呼吸杂志,2004,27(9)：589-592.
[7]Tongyoo S, Vilaichone W, Ratanarat R, et al. The effect of lateral position on oxygenation in ARDS patients:a pilot study[J]. J Med Assoc Thai.2006,89(Suppl 5): S55-61.
[8]Balibrea JL, Arias-Diaz J. Acute respiratory distress syndrome in the septic surgical patient[J]. World J Surg,2003,27(12):1275-1284.
[9]Heinze H, Sedemund-Adib B, Heringlake M,et al. The impact of different step changes of inspiratory fraction of oxygen on functional residual capacity measurements using the oxygen washout technique in ventilated patients[J]. Anesth Analg,2008,106(5):1491-1494.
[10]Heinze H, Sedemund-Adib B, Heringlake M, et al. Functional residual capacity changes after different endotracheal suctioning methods[J]. Anesth Analg,2008, 107(3):941-944.
[11]中华医学会重症医学分会.急性肺损伤/急性呼吸窘迫综合征诊断和治疗指南(2006)[J].中国危重病急救医学,2006,18(12)：706-710.
[12]Lu Y, Song Z, Zhou X, et al. A 12-month clinical survey of incidence and outcome of acute respiratory distress syndrome in Shanghai intensive care units[J]. Intensive Care Med,2004,30(12):2197-2203.
[13]Brower RG, Lanken PN, MacIntyre N, et al. Higher versus lower positive end-expiratory pressures in patients with acute respiratory distress syndrome[J]. N Eng J Med,2004,351(4):327-336.
[14]Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome[J]. N Engl J Med.2000;342(18):1301-1308.
[15]Halbertsma FJ, Vaneker M, Scheffer GJ, et al. Cytokines and biotrauma in ventilator-induced lung injury:a critical review of the literature[J]. Neth J Med,2005, 63(10):382.
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