CAJ | 학술논문

目的：比较不同潮气量水平通气对重症患者心脏舒张功能的影响。方法统计重庆市北部新区第一人民医院重症医学科2008～2013年进行机械通气的患者208例，在双水平正压通气（BIPA P ）模式下，调整吸气压使潮气量（VT）分别维持于6、8、10、15 mL／kg水平，其他呼吸机支持条件不变，以上各种条件维持30 min后测量中心静脉压（CVP）及血流动力学，心脏彩超监测左室射血分数（LEVF）。根据心脏指数（CI）分为心功能正常组（CI≥2．2 L·min-1·m -2）和心功能低下组（CI＜2．2 L·min-1·m-2），通气过程中若出现心率、血压明显下降或者恶性心律失常，则立即调整呼吸机参数。为排除 PEEP （呼气末正压）的影响，各组 PEEP均设定在5 cm H2 O 水平。结果在相同呼吸模式条件下，CI、胸内血容量指数（ITBVI）、舒张早期频谱幅度／舒张末期频谱幅度（E／A ）比值随着潮气量水平的升高而减小，平均气道压（Pmean），体循环血管阻力指数（SVRI）随着潮气量水平升高而升高，差异有统计学意义（P＜0．05）。而心率（HR）、LEVF在各组潮气量水平间无明显变化。心功能正常组在相同呼吸模式、相同呼吸支持条件下的CI、ITBVI、Pmean均无明显差异。心功能低下组患者中，8 mL／kg潮气量水平组CI较高，而在6、10、15 mL／kg潮气量水平组，CI较低，差异有统计学意义（P＜0．05）。结论在机械通气过程中应设置潮气量于6～8 mL／kg ，对血流动力学无明显影响，适用于心功能正常和心功能低下患者。
목적：비교불동조기량수평통기대중증환자심장서장공능적영향。방법통계중경시북부신구제일인민의원중증의학과2008～2013년진행궤계통기적환자208례，재쌍수평정압통기（BIPA P ）모식하，조정흡기압사조기량（VT）분별유지우6、8、10、15 mL／kg수평，기타호흡궤지지조건불변，이상각충조건유지30 min후측량중심정맥압（CVP）급혈류동역학，심장채초감측좌실사혈분수（LEVF）。근거심장지수（CI）분위심공능정상조（CI≥2．2 L·min-1·m -2）화심공능저하조（CI＜2．2 L·min-1·m-2），통기과정중약출현심솔、혈압명현하강혹자악성심률실상，칙립즉조정호흡궤삼수。위배제 PEEP （호기말정압）적영향，각조 PEEP균설정재5 cm H2 O 수평。결과재상동호흡모식조건하，CI、흉내혈용량지수（ITBVI）、서장조기빈보폭도／서장말기빈보폭도（E／A ）비치수착조기량수평적승고이감소，평균기도압（Pmean），체순배혈관조력지수（SVRI）수착조기량수평승고이승고，차이유통계학의의（P＜0．05）。이심솔（HR）、LEVF재각조조기량수평간무명현변화。심공능정상조재상동호흡모식、상동호흡지지조건하적CI、ITBVI、Pmean균무명현차이。심공능저하조환자중，8 mL／kg조기량수평조CI교고，이재6、10、15 mL／kg조기량수평조，CI교저，차이유통계학의의（P＜0．05）。결론재궤계통기과정중응설치조기량우6～8 mL／kg ，대혈류동역학무명현영향，괄용우심공능정상화심공능저하환자。
Objective To compare the effects of different tidal volume ventilation on cardiac diastolic function in severe cases .Methods A total of 208 cases ,receiving mechanical ventilation from 2008 to 2013 in Intensive Care Unit of the First People′s Hospital of Northern New District of Chongqing ,were enrolled .In the bi-level positive airway pressure (BIPAP) mode ,inspiratory pressure was adjusted to makes the tidal volume (VT) was maintained at 6 ,8 ,10 ,15 mL/kg .Central venous pressure (CVP) and hemodynamic indexes were detected ,and left ventricular ejec-tion fraction (LVEF) was monitored after the maintenance of condition ,mentioned above ,for 30 min ,when the other supportive conditions of respirator were kept as the same .According to the cardiac index (CI) ,patients were divided into normal heart function group (CI≥2 .2 L · min-1 · m -2 ) and poor cardiac function group (CI<2 .2 L · min-1 · m -2 ) .According to LEVF value ,patients were divided into systolic heart failure (LEVF<40% ) and diastolic heart failure (≥40% ) .Mechanical ventilation parameters were immediately adjusted ,when patient was with significant de-creasing of heart rate (HR) or blood pressure ,or malignant arrhythmia .To avoid the influence of positive end expira-tory pressure (PEEP) ,PEEP value was set at 5 cmH2 O in each group .Results At the same breath mode condition , CI ,intrathoracic blood volume index (ITBVI) ,early diastolic spectrum amplitude(peak E)/diastolic spectrum ampli-tude(peak A) ratio (E/A) decreased with the increasing of VT ,but mean airway pressure (Pmean) and systemic vascular resistance index (SVRI) increased ,all of which were with significant difference (P<0 .05) .While HR and LEVF were without significant difference between different groups (P> 0 .05) .Under the same breath mode and supportive conditions of respirator ,CI ,ITBVI and Pmean in patients with normal heart function were without signifi-cant difference between different group (P> 0 .05) .Among patients with poor cardiac function ,CI value was the highest in 8 mL/kg of VT group ,but was relatively low in 6 ,10 and 15 mL/kg of VT group ,which were with statis-tical difference (P<0 .05) .Conclusion The VT should be set to 6 -8 mL/kg during mechanical ventilation ,which might be without obvious influence on hemodynamics indexes and be applicable for the treatment of patients with normal or poor cardiac function .