适应性支持通气（ASV）术后撤机临床应用的研究
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摘要
目的适应性支持通气(ASV)与常规通气模式同步间歇指令通气(SIMV)在通气和撤机方面进行临床应用前瞻性研究对照,评价适应性支持通气(ASV)在术后撤机的临床应用价值。
方法选择2007年4月至2008年3月在天津医科大学总医院外科重症监护病房(SICU)收治的术后患者218例为研究对象,所有患者满足以下条件:均为气管插管静脉复合全麻手术后病人;术前无心肺功能障碍;术前动脉血血气分析基本正常:PaO2≥80mmHg,PaCO2≤50mmHg(未吸氧),PaO2/FiO2≥300 mmHg(吸氧);手术顺利,原发病得到解决;术前无肺感染征象、肝肾功能不全等情况。患者随机分为ASV和SIMV两组,分别给予适应性支持通气和同步间歇指令通气两种通气模式的机械通气,并按标准的脱机程序脱机。分析两组患者APACHEⅡ记分、机械通气时间、48小时内是否再次插管指标,血气分析、呼吸力学包括呼吸功(WOB)、气道闭合压(P0.1)、吸气时间压力乘积(PTP)、内源性呼气末正压(auto-PEEP)以及血液动力学等各项数据。所有数据采用均数士标准差((?)±s)表示,采用t检验及四格表x~2-检验,数据采用SPSS13.0软件包处理,以P＜0.05为差异显著、P＜0.01为差异非常显著。
结果两种模式机械通气患者APACHEⅡ记分、术前心肺功能、手术及麻醉情况均无显著差异。ASV组与SIMV组相比,潮气量(VT)较高(P＜0.05),总呼吸频率(fT)、气道峰压(P_(peak))、气道平均压(P_(mean))明显偏低(P＜0.05);病人所做的呼吸功(WOB)、气道闭合压(P_(0.1)),吸气时间压力乘积(PTP)亦明显降低(P＜0.05);内源性呼气末正压(auto-PEEP)发生率明显下降;患者对呼吸机耐受度提高;平均机械通气时间明显减少(P＜0.05)。提示两组病人具有可比性。而两组各项血气分析指标,血液动力学指标中包括平均动脉压(MBP)、中心静脉压(CVP)、心输出量(CO)等无显著差异(P＞0.05)。脱机成功率无显著差异。呼吸机肺气压伤,呼吸机相关性肺炎等带机并发症发生率无明显差异(P＞0.05)。
结论适应性支持通气(ASV)是根据病人呼吸力学情况自动调整通气参数,与同步间歇指令通气(SIMV)比较,ASV模式能获得与常规通气模式相似的通气目标,虽然本研究两种通气支持模式患者血流动力学影响、脱机成功率、呼吸机相关并发症方面,无明显区别。但ASV在降低气道压力,减少病人的做功,降低中枢呼吸驱动,降低内源性呼气末正压发生率等方面较SIMV具有优越性,增加了患者对呼吸机的耐受程度,缩短了平均机械通气时间。
Objective To evaluate the clinical value of Adapt Support Ventilation (ASV) applicated in mechanical ventilation by the way in comparing with a conventional venting mode, Synchronized Intermittent Mandatory Ventilation (SIMV).
Methods From April, 2007 to March, 2008, we took part Patients of Postop. treated in surgery intensive care unit in Tianjin medical university general hospital.all had been done endotracheal intubation and were postop. Patients. Their cardiorespiratory function, blood gas analysis (PaO_2≥80mmHg, PaCO_2≤50mmHg, PaO_2 /FiO_2≥200 mmHg ) , renal function ,Hepatic function were normal before operation,. All patients did not have lung infection signs before operation .and the operations were successful. All patients were randomly divided into two groups in which patients were treated with ASV and with SIMV modes. All patients were weaning in a standard procedure, patients' APACHE score, duration of mechanical ventilation ,results of weaning. In the mechanical ventilation period, also analyzed breathing mechanics consists of work of breathing(WOB), clogging press of airway(P_(0.1)), cross product of inspiratory time and pressure(PTP), and haemodynamics.
Results The APACHE score , Preoperative cardiorespiratory function, condition of narcotization or operation of the two grous didn't have significant difference. When grou1(ASV) compared grou2(SIMV), Tidal Volume (VT) was higher(P<0.05),total breathing frequency(fT), peak voltage of airway(Ppeak), mean pressure of airway(Pmean) were obviously lower(P<0.05);The patients' work of breathing(WOB), clogging press of airway(P0.1), cross product of inspiratory time and pressure(PTP) were obviously lower(P<0.05). Incidence rate of endogenous positive end expiratory pressure(auto-PEEP) dropped down. The patients' tolerance to breathing machine significantly rose. Average duration of mechanical ventilation significantly reduced. Which showed the two groups possessed comparability. Each index of blood gas analysis, each index of haemodynamics such as mean arterial blood pressure(MBP), central venous pressure(CVP), cardiac output(CO) of the two groups didn't have significant difference(P>0.05). Complication of mechanical ventilation such as pulmonary barotrauma of the two groups didn't have significant difference(P>0.05),The weaning achievement ratio didn't have significant difference(P>0.05)..
Conclusions Adapt Support Ventilation (ASV) mode can gain the same venting target as conventional ventilation , Synchronized Intermittent Mandatory Ventilation (SIMV),which autocontrols venting parameters on the basis of the patients' breathing mechanics. It is as same as SIMV in hemodynamics influence , weaning achievement ratio , mechanical ventilation complication ratio. But it is better than SIMV to cut down pressure of airway, to reduce work of breathing, to lower breathe drive of centre, and to cut down incidence rate of endogenous positive end expiratory pressure. ASV increases the patients' tolerance to breathing machine and shortened the average duration of mechanical ventilation.
方法选择2007年4月至2008年3月在天津医科大学总医院外科重症监护病房(SICU)收治的术后患者218例为研究对象,所有患者满足以下条件:均为气管插管静脉复合全麻手术后病人;术前无心肺功能障碍;术前动脉血血气分析基本正常:PaO2≥80mmHg,PaCO2≤50mmHg(未吸氧),PaO2/FiO2≥300 mmHg(吸氧);手术顺利,原发病得到解决;术前无肺感染征象、肝肾功能不全等情况。患者随机分为ASV和SIMV两组,分别给予适应性支持通气和同步间歇指令通气两种通气模式的机械通气,并按标准的脱机程序脱机。分析两组患者APACHEⅡ记分、机械通气时间、48小时内是否再次插管指标,血气分析、呼吸力学包括呼吸功(WOB)、气道闭合压(P0.1)、吸气时间压力乘积(PTP)、内源性呼气末正压(auto-PEEP)以及血液动力学等各项数据。所有数据采用均数士标准差((?)±s)表示,采用t检验及四格表x~2-检验,数据采用SPSS13.0软件包处理,以P＜0.05为差异显著、P＜0.01为差异非常显著。
结果两种模式机械通气患者APACHEⅡ记分、术前心肺功能、手术及麻醉情况均无显著差异。ASV组与SIMV组相比,潮气量(VT)较高(P＜0.05),总呼吸频率(fT)、气道峰压(P_(peak))、气道平均压(P_(mean))明显偏低(P＜0.05);病人所做的呼吸功(WOB)、气道闭合压(P_(0.1)),吸气时间压力乘积(PTP)亦明显降低(P＜0.05);内源性呼气末正压(auto-PEEP)发生率明显下降;患者对呼吸机耐受度提高;平均机械通气时间明显减少(P＜0.05)。提示两组病人具有可比性。而两组各项血气分析指标,血液动力学指标中包括平均动脉压(MBP)、中心静脉压(CVP)、心输出量(CO)等无显著差异(P＞0.05)。脱机成功率无显著差异。呼吸机肺气压伤,呼吸机相关性肺炎等带机并发症发生率无明显差异(P＞0.05)。
结论适应性支持通气(ASV)是根据病人呼吸力学情况自动调整通气参数,与同步间歇指令通气(SIMV)比较,ASV模式能获得与常规通气模式相似的通气目标,虽然本研究两种通气支持模式患者血流动力学影响、脱机成功率、呼吸机相关并发症方面,无明显区别。但ASV在降低气道压力,减少病人的做功,降低中枢呼吸驱动,降低内源性呼气末正压发生率等方面较SIMV具有优越性,增加了患者对呼吸机的耐受程度,缩短了平均机械通气时间。
Objective To evaluate the clinical value of Adapt Support Ventilation (ASV) applicated in mechanical ventilation by the way in comparing with a conventional venting mode, Synchronized Intermittent Mandatory Ventilation (SIMV).
Methods From April, 2007 to March, 2008, we took part Patients of Postop. treated in surgery intensive care unit in Tianjin medical university general hospital.all had been done endotracheal intubation and were postop. Patients. Their cardiorespiratory function, blood gas analysis (PaO_2≥80mmHg, PaCO_2≤50mmHg, PaO_2 /FiO_2≥200 mmHg ) , renal function ,Hepatic function were normal before operation,. All patients did not have lung infection signs before operation .and the operations were successful. All patients were randomly divided into two groups in which patients were treated with ASV and with SIMV modes. All patients were weaning in a standard procedure, patients' APACHE score, duration of mechanical ventilation ,results of weaning. In the mechanical ventilation period, also analyzed breathing mechanics consists of work of breathing(WOB), clogging press of airway(P_(0.1)), cross product of inspiratory time and pressure(PTP), and haemodynamics.
Results The APACHE score , Preoperative cardiorespiratory function, condition of narcotization or operation of the two grous didn't have significant difference. When grou1(ASV) compared grou2(SIMV), Tidal Volume (VT) was higher(P<0.05),total breathing frequency(fT), peak voltage of airway(Ppeak), mean pressure of airway(Pmean) were obviously lower(P<0.05);The patients' work of breathing(WOB), clogging press of airway(P0.1), cross product of inspiratory time and pressure(PTP) were obviously lower(P<0.05). Incidence rate of endogenous positive end expiratory pressure(auto-PEEP) dropped down. The patients' tolerance to breathing machine significantly rose. Average duration of mechanical ventilation significantly reduced. Which showed the two groups possessed comparability. Each index of blood gas analysis, each index of haemodynamics such as mean arterial blood pressure(MBP), central venous pressure(CVP), cardiac output(CO) of the two groups didn't have significant difference(P>0.05). Complication of mechanical ventilation such as pulmonary barotrauma of the two groups didn't have significant difference(P>0.05),The weaning achievement ratio didn't have significant difference(P>0.05)..
Conclusions Adapt Support Ventilation (ASV) mode can gain the same venting target as conventional ventilation , Synchronized Intermittent Mandatory Ventilation (SIMV),which autocontrols venting parameters on the basis of the patients' breathing mechanics. It is as same as SIMV in hemodynamics influence , weaning achievement ratio , mechanical ventilation complication ratio. But it is better than SIMV to cut down pressure of airway, to reduce work of breathing, to lower breathe drive of centre, and to cut down incidence rate of endogenous positive end expiratory pressure. ASV increases the patients' tolerance to breathing machine and shortened the average duration of mechanical ventilation.
引文
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4 毕俏杰,曲彦.PSV在机械通气撤机中的应用.山东医药.2000年第40卷第10期,24
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30 Tassaux D, Dalmas E, Gratadour P, and et al. Patient ventilator interactions during partial ventilatory support:a preliminary study comparing the effects of adaptive support ventilation with synchronized intermittent mandatory Ventilation plus inspiratory pressure support. Crit Carem ed,2002,30(4):801-807
31 Campbell RS, Branson RD, Johannigman JA. Adaptive support ventilation.Respir Care Clint,2001,7(3):425-440
32 Macintyre NR. Evidence-based guidelines for weaning and discontinuing ventilatory support:A collection task force facilitated by the American College of Chest Physicians,the American Association for Respiratory Care, and the American College of Critical Care Medicine. Chest,2001,120(6):375-395
33 Alexander H, Petter MD, Rene L. Automatic "Respirator/Weaning"with Adaptive Support Ventilation:The Effect on Duration of Endotracheal Intubation and Patient Management.Anesth Analg,2003,97(6): 1743-1750
34 Brunner JX,Iotti GA. Adaptive support ventilation (ASV). Minerva Anaesthesia,2002,68(5):365-368
35 Stein PD, Hull RD, Kayali F, et all Venous thrombo embolism according to age: the impact of an aging population Arch Intern Med, 2004, 164 (20): 2260-2265
36 Hart N , Hunt A , Polkey MI , et al . Comparison of proportional assist ventilation and pressure support ventilation in chronic respiratory failure due to neuromuscular and chest wall deformity [J] . Thorax , 2002 , 57 : 979 - 981.
37 Clough AV , Audi SH , Molthen RC , et al . Lung circulation modeling : status and prospect [J] . Proceeding of the IEEE , 2006 ,94 (4): 753 - 768.
38 Nucci G, Mergoni M, Bricchi C, et al. On-line monitoring of intrinsic PEEP in ventilator-dependent patients. J Appl Physiol, 2000, 89( 3): 985.
39 Imanaka H, Nishimura M, Miyano H, et al. Effect of synchronized intermittent mandatory ventilation on respiratory workload in infants after cardiac surgery.Anesthesiology, 2001, 95( 4): 881.
40 Road J, Jiang TX, Reid WD, et al. Weaning Failure,Muscle Injury. and Fatigue.Am J Respir Crit Care Med,2003, 168( 12) : 1539.
41 Cassina T, Chiolero R,Mauri R, et a 1. Clinical experience with adaptive support ventilation for fast-track cardiac surgery[J]. J Cardio Vasc Anesth, 2003, 17 (5) : 571-575.
42 Perrier A, Perneqer T, Cornuz J, et al 1 The COPD - PE sutdy: prevalence and predcition of pulmonary embolism in acuet exacerbations of chronci obsrtucitve pumlonary disease 1 Rev Mal Respir,2004, 21 (4): 791 - 796