俯卧位通气对急性呼吸窘迫综合征患者血液动力学的影响
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摘要
目的:观察不同病因所致急性呼吸窘迫综合征(ARDS)患者应用俯卧位通气(PPV)的临床效果及对血液动力学的影响。方法:选取44例ARDS患者,采取前瞻性对照研究方式,按照病因分为肺内源性组(23例)和肺外源性组(21例),给予俯卧位通气治疗;观察2组患者治疗前(P0)、治疗后1h(P1)、治疗后2h(P2)呼吸动力学指标(肺容积、Cst、PIP、Pplat)、血液动力学指标(MAP、CVP、HR、CI)、血气分析(Pa O_2、Pa CO_2、Pa O_2/Fi O_2、Sa O_2)及心、肾、凝血功能。结果:(1)应用PPV后1h、2h,2组患者肺容积、肺静态顺应性(Cst)均升高(均P<0.05);(2)肺外源性组P1、P2与P0比较,MAP、HR均下降明显(均P<0.05);肺内源性组P2与P0比较,MAP、HR均下降明显(均P<0.05);组间比较,P1时间点肺外源性组比肺内源性组MAP、HR均下降明显(均P<0.05);(3)肺内源性组P2时间点各指标优于P0(均P<0.05);肺外源性组P1、P2时间点各指标优于P0(均P<0.05);组间比较,P1时间点肺外源性组血气指标优于肺内源性组(P<0.05);(4)2组各时间点PT、APTT、D-二聚体、BNP、Cr、BUN指标比较差异无统计学意义(P>0.05)。结论:俯卧位通气可改善肺内/外源性ARDS患者氧合功能、血液动力学指标,肺外源性ARDS患者可较快改善患者氧合指数,提高回心血量;PPV对ARDS患者心、肾、凝血功能无明显影响。
Objective: To observe the clinical effect of prone position ventilation( PPV) in patients with acute respiratory distress syndrome( ARDS) with different causes and its influence on hemodynamics. Methods: 44 patients with ARDS were selected and prospectively controlled. The patients were divided into endogenous pulmonary group( 23 cases) and exogenous pulmonary group( 21 cases) according to different causes and both two groups were given PPV. Respiratory parameters( lung volume,Cst,PIP,Pplat),hemodynamic indexes( MAP,CVP,HR,CI),blood gas analysis( Pa O_2,Pa CO_2,Pa O_2/Fi O_2,Sa O_2),function of heart and kidney,and coagulation function indexes were observed before treatment( P0),1 h after treatment( P1),and 2 h after treatment( P2) in both two groups of patients. Results:(1) Pulmonary volume and lung static compliance( Cst) increased at P1 and P2 after PPV in both two groups( P < 0. 05).(2) In exogenous pulmonary group,MAP and HR decreased significantly at P1 and P2 as compared with those at P0( P < 0. 05),but in the endogenous pulmonary group,MAP and HR showed a significant decrease at P2( P < 0. 05). MAP and HR decreased significantly at P1 in the exogenous pulmonary group as compared with that in the endogenous pulmonary group( P < 0. 05).(3)Each index at P2 was superior to that at P0 in endogenous pulmonary group( P < 0. 05). Each index at P1 and P2 was superior to that at P0 in the exogenous pulmonary group( P < 0. 05). The blood gas index at P1 in the exogenous pulmonary group was superior to that in the endogenous pulmonary group( P < 0. 05).(4) There were no significant differences in PT,APTT,D-dimer,BNP,Cr and BUN between two groups at all time points( P > 0. 05). Conclusion: PPV can improve the oxygenation function and hemodynamic parameters of patients with pulmonary endogenous/exogenous ARDS. PPV can improve the oxygenation index and increase the return blood volume of patients with exogenous pulmonary ARDS. PPV had no effect on heart,kidney and coagulation function in patients with ARDS.
Objective: To observe the clinical effect of prone position ventilation( PPV) in patients with acute respiratory distress syndrome( ARDS) with different causes and its influence on hemodynamics. Methods: 44 patients with ARDS were selected and prospectively controlled. The patients were divided into endogenous pulmonary group( 23 cases) and exogenous pulmonary group( 21 cases) according to different causes and both two groups were given PPV. Respiratory parameters( lung volume,Cst,PIP,Pplat),hemodynamic indexes( MAP,CVP,HR,CI),blood gas analysis( Pa O_2,Pa CO_2,Pa O_2/Fi O_2,Sa O_2),function of heart and kidney,and coagulation function indexes were observed before treatment( P0),1 h after treatment( P1),and 2 h after treatment( P2) in both two groups of patients. Results:(1) Pulmonary volume and lung static compliance( Cst) increased at P1 and P2 after PPV in both two groups( P < 0. 05).(2) In exogenous pulmonary group,MAP and HR decreased significantly at P1 and P2 as compared with those at P0( P < 0. 05),but in the endogenous pulmonary group,MAP and HR showed a significant decrease at P2( P < 0. 05). MAP and HR decreased significantly at P1 in the exogenous pulmonary group as compared with that in the endogenous pulmonary group( P < 0. 05).(3)Each index at P2 was superior to that at P0 in endogenous pulmonary group( P < 0. 05). Each index at P1 and P2 was superior to that at P0 in the exogenous pulmonary group( P < 0. 05). The blood gas index at P1 in the exogenous pulmonary group was superior to that in the endogenous pulmonary group( P < 0. 05).(4) There were no significant differences in PT,APTT,D-dimer,BNP,Cr and BUN between two groups at all time points( P > 0. 05). Conclusion: PPV can improve the oxygenation function and hemodynamic parameters of patients with pulmonary endogenous/exogenous ARDS. PPV can improve the oxygenation index and increase the return blood volume of patients with exogenous pulmonary ARDS. PPV had no effect on heart,kidney and coagulation function in patients with ARDS.
引文
1韩炳智,韩韬,吴志峰.重症吸入性肺炎合并ARDS患者行俯卧位机械通气时氧合、血液动力学及气道引流的研究[J].中国呼吸与危重监护杂志,2014,13(1):78-81.
2 莫必华,刘艳秀,甘国能,等.重度ARDS患者应用俯卧位通气联合肺复张对血流动力学及预后的影响[J].临床肺科杂志,2015,20(11):2073-2075.
3 邹艳清,胡波,李建国,等.急性呼吸窘迫综合征机械通气治疗进展[J].内科急危重症杂志,2015,21(6):456-459.
4 Prat G,Guinard S,Bizien N,et al.Can lung ultrasonography predict prone positioning response in acute respiratory distress syndrome patients[J].J Crit Care,2016,32(1):36-41.
5 Sud S,Friedrich JO,Taccone P,et al.Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia:systematic review and meta-analysis[J].Intensive Care Med,2010,36(4):585-599.
6 尉玉杰,王磊,井慎,等.无创正压通气治疗轻度急性呼吸窘迫综合征的临床观察[J].内科急危重症杂志,2015,21(4):289-290.
7 Ashbaugh DG,Bigelow DB,Petty TL,et al.Acute respiratory distress in adults[J].Lancet,1967,290(7511):319-323.
8 Ud S,Friedrich JO,Adhikari NK,et al.Effect of prone positioning during mechanical ventilation on mortality among patients with acute respiratory distress syndrome:a systematic review and meta-analysis[J].CMAJ,2014,186(10):E381-390.
9 唐昊,梁泽平,蒋东坡,等.俯卧位通气在重症急性呼吸窘迫综合征临床救治中的价值[J].中国肺部疾病杂志(电子版),2016,9(4):377-380.
10 Santini A,Protti A,Langer T,et al.Prone position ameliorates lung elastance and increases functional residual capacity independently from lung recruitment[J].Intensive Care Med Exp,2015,3(1):55.
11 张欣,赵子平,刘宁,等.急性呼吸窘迫综合征小潮气量肺保护通气策略的预后分析[J].内科急危重症杂志,2015,21(2):120-121.
12 Kobirumaki-Shimozawa F,Inoue T,Shintani SA,et al.Cardiac thin filament regulation and the frank-starling mechanism[J].J Physiol Sci,2014,64(4):221-232.
13 Voelker MT,Jahn N,Bercker S,et al.Prone positioning of patients during venove nous extracorporeal membrane oxygenation is safe and feasible[J].Anaesthesist,2016,65(4):250-257.
14 Santini A,Protti A,Langer T,et al.Prone position ameliorates lung elastance and increases functional residual capacity independently from lung recruitment[J].Intensive Care Med Exp,2015,3(1):55.
15 陈思蓓,余裕恒,刘冬冬,等.俯卧位通气对伴间质性肺疾病的急性呼吸窘迫综合征患者血液动力学的影响[J].中国呼吸与危重监护杂志,2016,15(2):127-132.
2 莫必华,刘艳秀,甘国能,等.重度ARDS患者应用俯卧位通气联合肺复张对血流动力学及预后的影响[J].临床肺科杂志,2015,20(11):2073-2075.
3 邹艳清,胡波,李建国,等.急性呼吸窘迫综合征机械通气治疗进展[J].内科急危重症杂志,2015,21(6):456-459.
4 Prat G,Guinard S,Bizien N,et al.Can lung ultrasonography predict prone positioning response in acute respiratory distress syndrome patients[J].J Crit Care,2016,32(1):36-41.
5 Sud S,Friedrich JO,Taccone P,et al.Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia:systematic review and meta-analysis[J].Intensive Care Med,2010,36(4):585-599.
6 尉玉杰,王磊,井慎,等.无创正压通气治疗轻度急性呼吸窘迫综合征的临床观察[J].内科急危重症杂志,2015,21(4):289-290.
7 Ashbaugh DG,Bigelow DB,Petty TL,et al.Acute respiratory distress in adults[J].Lancet,1967,290(7511):319-323.
8 Ud S,Friedrich JO,Adhikari NK,et al.Effect of prone positioning during mechanical ventilation on mortality among patients with acute respiratory distress syndrome:a systematic review and meta-analysis[J].CMAJ,2014,186(10):E381-390.
9 唐昊,梁泽平,蒋东坡,等.俯卧位通气在重症急性呼吸窘迫综合征临床救治中的价值[J].中国肺部疾病杂志(电子版),2016,9(4):377-380.
10 Santini A,Protti A,Langer T,et al.Prone position ameliorates lung elastance and increases functional residual capacity independently from lung recruitment[J].Intensive Care Med Exp,2015,3(1):55.
11 张欣,赵子平,刘宁,等.急性呼吸窘迫综合征小潮气量肺保护通气策略的预后分析[J].内科急危重症杂志,2015,21(2):120-121.
12 Kobirumaki-Shimozawa F,Inoue T,Shintani SA,et al.Cardiac thin filament regulation and the frank-starling mechanism[J].J Physiol Sci,2014,64(4):221-232.
13 Voelker MT,Jahn N,Bercker S,et al.Prone positioning of patients during venove nous extracorporeal membrane oxygenation is safe and feasible[J].Anaesthesist,2016,65(4):250-257.
14 Santini A,Protti A,Langer T,et al.Prone position ameliorates lung elastance and increases functional residual capacity independently from lung recruitment[J].Intensive Care Med Exp,2015,3(1):55.
15 陈思蓓,余裕恒,刘冬冬,等.俯卧位通气对伴间质性肺疾病的急性呼吸窘迫综合征患者血液动力学的影响[J].中国呼吸与危重监护杂志,2016,15(2):127-132.