侧卧位通气对ARDS患者肺容积和氧合的影响
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摘要
目的:探讨侧卧位通气对急性呼吸窘迫综合征(ARDS)患者肺容积和氧合的影响。方法:对14例收治ICU的ARDS机械通气患者采用容量控制通气的模式,均先后行仰卧位、侧卧位、仰卧位通气各1h。各体位通气结束时测定患者呼气末容积(EELV)、气道峰压(PIP)、气道平台压(P_(plat))、气道平均压(P_m)、静态肺顺应性(Cst)、气道阻力(Raw)等指标,行血气分析并记录平均血压(MAP)、心率(HR)。结果:(1)肺容积的变化:EELV侧卧位后由(1109±321)ml增加到(1376±297)ml(P<0.05),恢复仰卧位后下降至(1165±264)ml(P<0.05),而恢复仰卧位后与初始仰卧位相比无显著差异(P>0.05)。(2)气体交换的变化:氧合指数(PaO_2/FiO_2)侧卧位后由(154.3±35.O)mmHg(1 mmHg=0.133 KPa)增加到(189.9±60.1)mmHg(P<0.05),恢复仰卧位后继续增加至(209.2±75.4)mmHg(P<0.05)并较初始仰卧位明显增加(P<0.01);体位改变后动脉血二氧化碳分压(PaCO_2)变化无统计学意义(P>0.05)。(3)肺机械力学的变化:体位改变后PIP、P_(plat)、P_m、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:体位改变后MAP和HR变化均无统计学意义(P均>0.05)。结论:ARDS机械通气患者采用侧卧位通气后可增加EELV并改善氧合。
Objective:To study the effects of lateral position ventilation on lung volume and oxygenation in patients with acute respiratory distress syndrome(ARDS).Methods: Fourteen patients with ARDS were ventilated in volume controlled.Supine position, lateral position and supine position were successively adopted in each patient and each position continued for 1h.End expiratory lung volume(EELV),peak inspiratory pressure(PIP),plateau airway pressure(P_(plat)),mean airway pressure(P_m),airway resistance(Raw),static pulmonary compliance(Cst),heart rate(HR),mean artery pressure(MAP) and arterial blood gas were measured at the end of each epoch.Results:
(1) The change of lung volume:EELV increased from(1109±321) ml to(1376±297) ml after lateral ventilation(P<0.05) and decreased to(1165±264) ml after resumed supine ventilation(P<0.05).Compared with initial supine ventilation,there was no significant difference in EELV after resumed supine ventilation(P>0.05).(2) The change of gas exchanges:Arterial oxygenation index(PaO_2/FiO_2) increased from(154.3±35.0) mmHg to(189.9±60.1) mmHg after lateral ventilation(P<0.05) and increased to(209.2±75.4) mmHg after resumed supine ventilation(P<0.05).Compared with initial supine ventilation,PaO_2/FiO_2 increased greatly after resumed supine ventilation(P <0.01).There was no significant difference in partial pressure of arterial carbon dioxide (PaCO_2) after change of positions(P>0.05).(3) The change of lung mechanics:There were no significant differences in PIP,P_m,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:The use of lateral position ventilation can increase EELV and improve oxygenation in patients with ARDS.
Objective:To study the effects of lateral position ventilation on lung volume and oxygenation in patients with acute respiratory distress syndrome(ARDS).Methods: Fourteen patients with ARDS were ventilated in volume controlled.Supine position, lateral position and supine position were successively adopted in each patient and each position continued for 1h.End expiratory lung volume(EELV),peak inspiratory pressure(PIP),plateau airway pressure(P_(plat)),mean airway pressure(P_m),airway resistance(Raw),static pulmonary compliance(Cst),heart rate(HR),mean artery pressure(MAP) and arterial blood gas were measured at the end of each epoch.Results:
(1) The change of lung volume:EELV increased from(1109±321) ml to(1376±297) ml after lateral ventilation(P<0.05) and decreased to(1165±264) ml after resumed supine ventilation(P<0.05).Compared with initial supine ventilation,there was no significant difference in EELV after resumed supine ventilation(P>0.05).(2) The change of gas exchanges:Arterial oxygenation index(PaO_2/FiO_2) increased from(154.3±35.0) mmHg to(189.9±60.1) mmHg after lateral ventilation(P<0.05) and increased to(209.2±75.4) mmHg after resumed supine ventilation(P<0.05).Compared with initial supine ventilation,PaO_2/FiO_2 increased greatly after resumed supine ventilation(P <0.01).There was no significant difference in partial pressure of arterial carbon dioxide (PaCO_2) after change of positions(P>0.05).(3) The change of lung mechanics:There were no significant differences in PIP,P_m,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:The use of lateral position ventilation can increase EELV and improve oxygenation in patients with ARDS.
引文
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[5]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.
[6]黄国华,陈正贤.急性肺损伤和急性呼吸窘迫综合征的诊治思维程序[J].中国实用内科杂志,2007,27(9):1480-1482.
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[8]张翔宇.肺保护机械通气策略的进展与临床评价[J].同济大学学报(医学版),2008,29(3):4-6.
[9]The 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.
[10]Herrera MT,Toledo C,Valladares F,et al.Positive end-expiratory pressure modulates local and systemic inflammatory responses in a sepsis-induced lung injury model[J].Intensive Care Med,2003,29(8):1345-1353.
[11]Parsons PE,Matthay MA,Ware LB,et al.Elevated plasma levels of soluble TNF receptors are associated with morbidity and mortality in patients with acute lung injury[J].Am J Physiol Lung Cell Mol Physiol,2005,288(3):L426-431.
[12]Gurkan OU,O'Donnell C,Brower R,et al.Differential effects of mechanical ventilatory strategy on lung injury and systemic organ inflammation in mice[J].Am J Physiol Lung Cell Mol Physiol,2003,285(3):L710-718.
[13]Abdulnour RE,Peng X,Finigan JH,et al.Mechanical stress activates xanthine oxidoreductase through MAP kinase-dependent pathways[J].Am J Physiol Lung Cell Mol Physiol,2006,291(3):L345-353.
[14]Rotta AT,Gunnarsson B,Fuhrman BP,et al.Comparison of lung protective ventilation strategies in a rabbit model of acute lung injury[J].Crit Care Med,2001,29(11):2176-2184.
[15]Laffey JG,Engelberts D,Kavanagh BP.Buffering hypercapnic acidosis worsens acute lung injury[J].Am J Respir Crit Care Med,2000,161(1):141-146.
[16]Piehl MA,Brown RS.Use of extreme position changes in respiratory failure[J].Crit Care Med,1976,4(1):13-14.
[17]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.
[18]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.
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