CAJ | 학술논문

目的探讨俯卧位通气联合肺复张对重度急性呼吸窘迫综合征(ARDS)患者预后的影响.方法依据ARDS“柏林标准”将入选的重度ARDS患者随机分为标准通气组和早期俯卧位通气联合肺复张组(简称联合通气组).标准通气组采用保护性机械通气策略,联合通气组在保护性机械通气策略的基础上采用俯卧位通气联合肺复张的方法进行机械通气.观察2组患者氧合指数、气道平台压、静态肺顺应性、28 d病死率、ICU留治时间、机械通气时间、气管切开率、人工气道拔除时间、气胸和压疮发生率.结果 (1)共入选重度ARDS患者116例,标准通气组60例,联合通气组56例,2组基线资料差异无统计学意义(P值均＞0.05).(2)早期俯卧位通气联合肺复张后,联合通气组氧合指数[(176-24)mmHg(1 mmHg =0.133 kPa)]高于标准通气组[(138±37) mmHg;P ＜0.01],呼气末正压(PEEP)水平[(8±2)cmH2O(1 cmH2O=0.098 kPa)比(10±2)cmH2O;P=0.001]、吸入氧浓度(FiO2)[(0.50±0.12)％比(0.60±0.10)％]低于标准通气组(P＜0.01),而气道平台压、静态肺顺应性2组间无差别.(3)与标准通气组比,联合通气组ICU留治时间[(22±19)d比(26±22)d]、机械通气时间缩短[(13±6)d比(19±7)d;P值均＜0.05],28 d病死率下降(16.1％比33.3％;P＜0.05),气管切开率、人工气道拔除时间2组间无差异.(4)Ⅰ级压疮发生率联合通气组(53.6％)高于标准通气组(10.0％;P＜0.01),气胸发生率、Ⅱ级压疮发生率2组间无差异,2组均未发生Ⅲ级或Ⅳ级压疮.结论早期俯卧位通气联合肺复张能改善重度ARDS患者氧合及预后,且不增加严重并发症的发生率.
목적 탐토부와위통기연합폐복장대중도급성호흡군박종합정(ARDS)환자예후적영향.방법 의거ARDS“백림표준”장입선적중도ARDS환자수궤분위표준통기조화조기부와위통기연합폐복장조(간칭연합통기조).표준통기조채용보호성궤계통기책략,연합통기조재보호성궤계통기책략적기출상채용부와위통기연합폐복장적방법진행궤계통기.관찰2조환자양합지수、기도평태압、정태폐순응성、28 d병사솔、ICU류치시간、궤계통기시간、기관절개솔、인공기도발제시간、기흉화압창발생솔.결과 (1)공입선중도ARDS환자116례,표준통기조60례,연합통기조56례,2조기선자료차이무통계학의의(P치균＞0.05).(2)조기부와위통기연합폐복장후,연합통기조양합지수[(176-24)mmHg(1 mmHg =0.133 kPa)]고우표준통기조[(138±37) mmHg;P ＜0.01],호기말정압(PEEP)수평[(8±2)cmH2O(1 cmH2O=0.098 kPa)비(10±2)cmH2O;P=0.001]、흡입양농도(FiO2)[(0.50±0.12)％비(0.60±0.10)％]저우표준통기조(P＜0.01),이기도평태압、정태폐순응성2조간무차별.(3)여표준통기조비,연합통기조ICU류치시간[(22±19)d비(26±22)d]、궤계통기시간축단[(13±6)d비(19±7)d;P치균＜0.05],28 d병사솔하강(16.1％비33.3％;P＜0.05),기관절개솔、인공기도발제시간2조간무차이.(4)Ⅰ급압창발생솔연합통기조(53.6％)고우표준통기조(10.0％;P＜0.01),기흉발생솔、Ⅱ급압창발생솔2조간무차이,2조균미발생Ⅲ급혹Ⅳ급압창.결론 조기부와위통기연합폐복장능개선중도ARDS환자양합급예후,차불증가엄중병발증적발생솔.
Objective To evaluate the effects of prone position ventilation combined with recruitment maneuvers(RM) on clinical outcomes in patients with severe acute respiratory distress syndrome (ARDS).Methods In this prospective,randomized,controlled trial,we randomly assigned 116 sequential patients with severe ARDS to the intervention group (which undergo prone-positioning with RM sessions of at least 10 hours) or to the control group (which be left in the supine position).Results From July 2012 to July 2013,116 severe ARDS patients sequentially admitted to the critical department of Peking Union Medical College Hospital were enrolled in the study with 60 patients assigned to the control group and 56 patients to the intervention group.No significant difference was found between the two groups in the demographics including the median patient age,sex ratio,initial Acute Physiology and Chronic Health Evaluation Ⅱ scores,initial pulmonary function and the sources of ARDS.The oxygenation index recorded in the supine position was significantly higher in the intervention group than in the control group since day 3,whereas the positive end-expiratory pressure and fraction of inspired O2 were significantly lower in the intervention group.The plateau pressure and static compliance of the respiratory system were similar in the two groups.The intervention group had shorter length of ICU stay,fewer ventilation days and decreased 28-day mortality than the control group.The tracheotomy ratio and the time to successful extubation were similar in the two groups.No significant difference between the two groups was shown in the incidence of complications,except for the grade 1 pressure sore,which was higher in the intervention group.Conclusions In patients with severe ARDS,application of prolonged prone-positioning with RM sessions significantly improves the clinical outcomes.