肺复张对肺内/外源性急性呼吸窘迫综合征模型犬呼吸生理和肺形态学影响的比较
폐복장대폐내/외원성급성호흡군박종합정모형견호흡생리화폐형태학영향적비교
Comparative study of recruitment maneuver guided by pressure-volume curve on respiratory physiology and lung morphology between acute respiratory distress syndrome of pulmonary and extrapulmonary origin in canine models
  • 万方数据
    中国危重病急救医学 중국위중병급구의학
    CHINESE CRITICAL CARE MEDICINE
    2011年 1期 36-39 ,共4页

    熊旭明%温德良%温艺超%刘卫江

    웅욱명%온덕량%온예초%류위강

    急性呼吸窘迫综合征%肺复张%肺保护通气策略%压力-容积曲线 急性呼吸窘迫綜閤徵%肺複張%肺保護通氣策略%壓力-容積麯線
    급성호흡군박종합정%폐복장%폐보호통기책략%압력-용적곡선
    Acute respiratory distress syndrome%Recruitment maneuver%Lung protective ventilation strategy%Pressure-volume curve
    目的 探讨以压力-容积(P-V)曲线为导向的肺复张(RM)策略对肺内/外源性急性呼吸窘迫综合征(ARDSexp/ARDSp)模型犬呼吸生理和肺形态学的影响.方法 将24只健康杂种犬按随机数字表法均分为两组,分别以静脉注射油酸0.1 ml/kg复制ARDSexp模型,以气管内注入盐酸2 ml/kg复制ARDSp模型.每种模型再随机均分为肺保护通气策略(LPVS)组和LPVS+RM组.LPVS组采用LPVS进行机械通气(MV);LPVS+RM组先进行以P-V曲线为导向的RM,RM采用压力控制通气(PCV),压力上限为高位转折点(UIP),呼气末正压(PEEP)为低位转折点(LLP)+2 cm H2O(1 cm H2O=0.098 kPa),维持60 s后再按LPVS进行MV.两组MV时间均为4 h.观察动物基础状态(成模前)及RM前后的氧合指数(PaO2/FiO2)、呼吸力学指标变化;采用低流速法记录准静态P-V曲线并计算UIP、LIP ;根据肺CT比较不同肺充气区容积占全肺容积的百分比.结果 成模前和RM前两组PaO2/FiO2及UIP、LIP比较差异均无统计学意义.RM后4 h,两种模型LPVS+RM组PaO2/FiO2和肺顺应性(Crs)均较同模型LPVS组显著升高[ARDSexp模型PaO,/FiO2(mm Hg,1 mm Hg=0.133 kPa):263.9±69.2比182.8±42.8,Crs(ml/cm H2O):11.3±4.2比9.7±3.7;ARDSp模型PaO2/FiO2(mm Hg):193.4±33.5比176.4±40.2,Crs(ml/cm H2O):10.1±3.9比9.0±3.9,P＜0.05或P＜0.01],气道压力明显低于同模型LPVS组[ARDSexp模型吸气峰压(PIP,cm H2O):24.1±7.4比30.2±8.5,气道平台压(Pplat,cm H2O):19.1±7.3比25.6±7.7;ARDSp模型PIP(cm H2O):26.6±8.4比29.6±10.3,Pplat(cm H2O):21.9±7.3比25.1±8.4,P＜0.05或P＜0.01];且ARDSexp模型改善程度较ARDSp模型更为显著(P＜0.05或P＜0.01).两种模型LPVS+RM组肺组织闭合区和充气不足区所占比例均较同模型LPVS组明显减少,正常充气区所占比例明显增加[ARDSexp模型闭合区:(9.9±3.1)%比(16.3±5.2)%,充气不足区:(10.2±4.2)%比(23.4±6.7)%,正常充气区:(76.2±12.3)%比(57.5±10.1)%;ARDSp模型闭合区:(14.3±4.8)%比(1 8.2±5.1)%,充气不足区:(17.4±6.3)%比(24.1±5.9)%,正常充气区:(63.2±10.7)%比(54.6±11.3)%,P＜0.05或P＜0.01];且ARDSexp模型各充气区所占比例改善程度均明显优于ARDSp模型(均P＜0.05).结论 对于不同原因ARDS,以P-V曲线为导向的RM均具有增加肺氧合、改善肺顺应性和肺组织通气的作用,且对ARDSexp的治疗效果明显优于ARDSp.
    목적 탐토이압력-용적(P-V)곡선위도향적폐복장(RM)책략대폐내/외원성급성호흡군박종합정(ARDSexp/ARDSp)모형견호흡생리화폐형태학적영향.방법 장24지건강잡충견안수궤수자표법균분위량조,분별이정맥주사유산0.1 ml/kg복제ARDSexp모형,이기관내주입염산2 ml/kg복제ARDSp모형.매충모형재수궤균분위폐보호통기책략(LPVS)조화LPVS+RM조.LPVS조채용LPVS진행궤계통기(MV);LPVS+RM조선진행이P-V곡선위도향적RM,RM채용압력공제통기(PCV),압력상한위고위전절점(UIP),호기말정압(PEEP)위저위전절점(LLP)+2 cm H2O(1 cm H2O=0.098 kPa),유지60 s후재안LPVS진행MV.량조MV시간균위4 h.관찰동물기출상태(성모전)급RM전후적양합지수(PaO2/FiO2)、호흡역학지표변화;채용저류속법기록준정태P-V곡선병계산UIP、LIP ;근거폐CT비교불동폐충기구용적점전폐용적적백분비.결과 성모전화RM전량조PaO2/FiO2급UIP、LIP비교차이균무통계학의의.RM후4 h,량충모형LPVS+RM조PaO2/FiO2화폐순응성(Crs)균교동모형LPVS조현저승고[ARDSexp모형PaO,/FiO2(mm Hg,1 mm Hg=0.133 kPa):263.9±69.2비182.8±42.8,Crs(ml/cm H2O):11.3±4.2비9.7±3.7;ARDSp모형PaO2/FiO2(mm Hg):193.4±33.5비176.4±40.2,Crs(ml/cm H2O):10.1±3.9비9.0±3.9,P＜0.05혹P＜0.01],기도압력명현저우동모형LPVS조[ARDSexp모형흡기봉압(PIP,cm H2O):24.1±7.4비30.2±8.5,기도평태압(Pplat,cm H2O):19.1±7.3비25.6±7.7;ARDSp모형PIP(cm H2O):26.6±8.4비29.6±10.3,Pplat(cm H2O):21.9±7.3비25.1±8.4,P＜0.05혹P＜0.01];차ARDSexp모형개선정도교ARDSp모형경위현저(P＜0.05혹P＜0.01).량충모형LPVS+RM조폐조직폐합구화충기불족구소점비례균교동모형LPVS조명현감소,정상충기구소점비례명현증가[ARDSexp모형폐합구:(9.9±3.1)%비(16.3±5.2)%,충기불족구:(10.2±4.2)%비(23.4±6.7)%,정상충기구:(76.2±12.3)%비(57.5±10.1)%;ARDSp모형폐합구:(14.3±4.8)%비(1 8.2±5.1)%,충기불족구:(17.4±6.3)%비(24.1±5.9)%,정상충기구:(63.2±10.7)%비(54.6±11.3)%,P＜0.05혹P＜0.01];차ARDSexp모형각충기구소점비례개선정도균명현우우ARDSp모형(균P＜0.05).결론 대우불동원인ARDS,이P-V곡선위도향적RM균구유증가폐양합、개선폐순응성화폐조직통기적작용,차대ARDSexp적치료효과명현우우ARDSp.
    Objective To determine effects of recruitment maneuver (RM) guided by pressure-volume (P-V) curve on respiratory physiology and lung morphology in canine models of acute respiratory distress syndrome of pulmonary or extrapulmonary origin (ARDSp and ARDSexp). Methods Twenty-four healthy dogs were randomly divided into two groups with 12 dogs each: ARDSexp and ARDSp. Each dog in ARDSexp group was injected with oleic acid 0. 1 ml/kg through femoral vein, and each dog in ARDSp group received hydrochloric acid 2 ml/kg via trachea. Subsequently, dogs with both models were randomly subdivided into lung protective ventilation strategy (LPVS) group and LPVS+RM group, respectively. Dogs in LPVS group were given LPVS only without RM. RM guided by P-V curve was performed in LPVS+RM group followed by LPVS and pressure controlled ventilation (PCV) mode was selected. Phigh was set at upper inflection point (UIP) of the P-V curve, positive end-expiratory pressure (PEEP) was set at lower inflection point (LIP)+2 cm H2O (1 cm H2O=0. 098 kPa), and the duration of RM was 60 seconds. The duration of mechanical ventilation (MV) in both subgroups was 4 hours. The oxygenation index (PaO2/FiO2), relative lung mechanical indexes were measured in two ARDS models before establishment of ARDS model, and before and after RM. The UIP and LIP were calculated with P-V curve. The percentage of different volume in ventilation of lung accounting for total lung volume was compared by CT scan.Results The PaO2/FiO2, UIP and LIP did not showed significant differences among all groups before ARDSand before RM. PaO2/FiO2 and respiratory system compliance (Crs) were significantly elevated in LPVS+RM group of both models 4 hours after RM compared with corresponding LPVS group [PaO2/FiO2(mm Hg,1 mm Hg=0. 133 kPa) of ARDSexp model: 263. 9±69. 2 vs. 182.8±42. 8, Crs (ml/cm H2O) of ARDSexp model: 11.3±4. 2 vs. 9. 7±3. 7; PaO2/FiO2(mm Hg) of ARDSp model: 193. 4±33.5 vs. 176. 4±40. 2, Crs (ml/cm H2O) of ARDSp model: 10.1±3.9 vs. 9.0±3.9, P＜0. 05 or P＜0.01], and the airway pressure was significantly declined compared with corresponding LPVS group [peak inspiratory pressure (PIP),cm H2O) of ARDSexp model: 24. 1±7. 4 vs. 30. 2±8. 5, plateau pressure (Pplat, cm H2O) of ARDSexp model: 19.1±7.3 vs. 25.6±7.7; PIP (cm H2O) of ARDSp model: 26.6±8.4 vs. 29.6±10.3, Pplat (cm H2O) of ARDSp model: 21.9±7. 3 vs. 25.1±8.4, P＜0. 05 or P＜0. 01]. Moreover, PaO2/FiO2, Crs,PIP and Pplat were improved better in ARDSexp model than ARDSp model (P＜ 0. 05 or P＜ 0. 01).Compared with LPVS maneuver, RM plus LPVS maneuver could significantly decrease the proportion of closure and hypoventilation region, and increase the proportion of normal ventilation region in both models [closure region of ARDSexp model : (9.9±3.1) % vs. (16. 3± 5. 2) %, hypoventilation region of ARDSexp model: (10. 2±4.2)% vs. (23. 4±6. 7)%, normal ventilation region of ARDSexp model: (76. 2±12. 3)%vs. (57.5±10. 1)%; closure region of ARDSp model: (14.3±4. 8)% vs. (18. 2±5.1)%, hypoventilation region of ARDSp model : (17.4±6. 3) % vs. ( 24. 1 ± 5. 9) 0%, normal ventilation region of ARDSp model :(63. 2 ± 10. 7 ) % vs. ( 54. 6±11.3 ) %, P ＜ 0. 05 or P ＜ 0. 01]. All of the ventilation regions were better improved with ARDSexp model than ARDSp model (all P＜0. 05). Conclusion RM guided by P-V curve could help obtain better oxygenation, improve pulmonary compliance and lung ventilation in ARDSexp and ARDSp, and better treatment effects are seen in ARDSexp dogs than ARDSp dogs.
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