CAJ | 학술논문

目的探讨肺保护性通气策略联合肺复张对严重烧伤并发ARDS患者的疗效. 方法分析2011年9月-2013年9月笔者单位烧伤ICU收治的15例符合纳入标准的烧伤并发ARDS患者资料.患者自确诊为急性肺损伤/ARDS时起,即采用肺保护性通气策略行机械通气,当氧合指数(OI)≤200 mmHg(1 mmHg =0.133 kPa)时,联合应用呼气末正压递增法行肺复张;OI ＞200 mmHg时结束肺复张,继续行肺保护性通气策略通气;OI＞ 300 mmHg时,停止机械通气.分别于联合肺复张前、肺复张24 h及肺复张结束时采用血气分析仪测定本组患者血气分析指标pH值、PaO2、PaCO2,并计算OI;动态监测本组患者血流动力学参数心率、平均动脉压(MAP)、中心静脉压(CVP)及4例行脉搏轮廓心排血量(PiCCO)监测患者的心排血量(CO)、血管外肺水指数(EVLWI).统计患者的治疗情况及结果.对数据行单组资料的重复测量方差分析和LSD检验. 结果 (1)联合肺复张前、肺复张24 h及肺复张结束时,本组患者PaO2和OI分别为(77±8)、(11 3±5)、(142±6) mmHg,(128±12)、(188 ±8)、(237±10) mmHg.各时相点间总体比较,PaO2和OI变化明显(F值分别为860.96和842.09,P值均小于0.01),pH值和PaCO2无明显变化(F值分别为0.35和3.13,P值均大于0.05).(2)各时相点间总体比较,本组患者心率、MAP、CVP及4例行PiCCO监测患者CO无明显变化(F值为0.13 ～4.26,P值均大于0.05).4例行PiCCO监测患者联合肺复张前、肺复张24 h及肺复张结束时EVLWI分别为(13.5±1.3)、(10.2±1.0)、(7.0±0.8)mL/kg,差异明显(F=117.00,P＜ 0.01).(3)本组患者于伤后2～72 h行机械通气,持续14～32(21 ±13)d;伤后3～14(7±5)d,联合应用肺复张2 ～5(3.0 ±2.0)d.15例患者均治愈,未出现其他并发症. 结论肺保护性通气策略联合肺复张可以明显改善严重烧伤并发ARDS患者的氧合,并可能因此而改善预后.
목적 탐토폐보호성통기책략연합폐복장대엄중소상병발ARDS환자적료효. 방법 분석2011년9월-2013년9월필자단위소상ICU수치적15례부합납입표준적소상병발ARDS환자자료.환자자학진위급성폐손상/ARDS시기,즉채용폐보호성통기책략행궤계통기,당양합지수(OI)≤200 mmHg(1 mmHg =0.133 kPa)시,연합응용호기말정압체증법행폐복장;OI ＞200 mmHg시결속폐복장,계속행폐보호성통기책략통기;OI＞ 300 mmHg시,정지궤계통기.분별우연합폐복장전、폐복장24 h급폐복장결속시채용혈기분석의측정본조환자혈기분석지표pH치、PaO2、PaCO2,병계산OI;동태감측본조환자혈류동역학삼수심솔、평균동맥압(MAP)、중심정맥압(CVP)급4례행맥박륜곽심배혈량(PiCCO)감측환자적심배혈량(CO)、혈관외폐수지수(EVLWI).통계환자적치료정황급결과.대수거행단조자료적중복측량방차분석화LSD검험. 결과 (1)연합폐복장전、폐복장24 h급폐복장결속시,본조환자PaO2화OI분별위(77±8)、(11 3±5)、(142±6) mmHg,(128±12)、(188 ±8)、(237±10) mmHg.각시상점간총체비교,PaO2화OI변화명현(F치분별위860.96화842.09,P치균소우0.01),pH치화PaCO2무명현변화(F치분별위0.35화3.13,P치균대우0.05).(2)각시상점간총체비교,본조환자심솔、MAP、CVP급4례행PiCCO감측환자CO무명현변화(F치위0.13 ～4.26,P치균대우0.05).4례행PiCCO감측환자연합폐복장전、폐복장24 h급폐복장결속시EVLWI분별위(13.5±1.3)、(10.2±1.0)、(7.0±0.8)mL/kg,차이명현(F=117.00,P＜ 0.01).(3)본조환자우상후2～72 h행궤계통기,지속14～32(21 ±13)d;상후3～14(7±5)d,연합응용폐복장2 ～5(3.0 ±2.0)d.15례환자균치유,미출현기타병발증. 결론 폐보호성통기책략연합폐복장가이명현개선엄중소상병발ARDS환자적양합,병가능인차이개선예후.
Objective To investigate the effects of lung protective ventilation strategy combined with lung recruitment maneuver on ARDS complicating patients with severe burn.Methods Clinical data of 15 severely burned patients with ARDS admitted to our burn ICU from September 2011 to September 2013 and conforming to the study criteria were analyzed.Right after the diagnosis of acute lung injury/ARDS,patients received mechanical ventilation with lung protective ventilation strategy.When the oxygenation index (OI) was below or equal to 200 mmHg (1 mmHg =0.133 kPa),lung recruitment maneuver was performed combining incremental positive end-expiratory pressure.When OI was above 200 mmHg,lung recruitment maneuver was stopped and ventilation with lung protective ventilation strategy was continued.When OI was above 300 mmHg,mechanical ventilation was stopped.Before combining lung recruitment maneuver,24 h after combining lung recruitment maneuver,and at the end of combining lung recruitment maneuver,variables of blood gas analysis (pH,PaO2,and PaCO2) were obtained by blood gas analyzer,and the OI values were calculated; hemodynamic parameters including heart rate,mean arterial pressure (MAP),central venous pressure (CVP) of all patients and the cardiac output (CO),extravascular lung water index (EVLWI)of 4 patients who received pulse contour cardiac output (PiCCO) monitoring were monitored.Treatment measures and outcome of patients were recorded.Data were processed with analysis of variance of repeated measurement of a single group and LSD test.Results (1) Before combining lung recruitment maneuver,24 h after combining lung recruitment maneuver,and at the end of combining lung recruitment maneuver,the levels of PaO2 and OI of patients were respectively (77 ±8),(113 ±5),(142 ±6) mmHg,and (128 ±12),(188 ±8),(237 ± 10) mmHg.As a whole,levels of PaO2 and OI changed significantly at different time points (with F values respectively 860.96 and 842.09,P values below 0.01) ; levels of pH and PaCO2 showed no obvious changes (with F values respectively 0.35 and 3.13,P values above 0.05).(2) Levels of heart rate,MAP,CVP of all patients and CO of 4 patients who received PiCCO monitoring showed no significant changes at different time points (with F values from 0.13 to 4.26,P values above 0.05).Before combining lung recruitment maneuver,24 h after combining lung recruitment maneuver,and at the end of combining lung recruitment maneuver,the EVLWI values of 4 patients who received PiCCO monitoring were respectively (13.5 ±1.3),(10.2±1.0),(7.0 ±0.8) mL/kg (F =117.00,P ＜0.01).(3) The patients received mechanical ventilation at 2 to 72 h after burn,lasting for 14-32 (21 ± 13) d.At post injury day 3-14 (7 ±5) d,lung recruitment maneuver was applied for 2-5 (3.0 ±2.0) d.All 15 patients recovered without other complications.Conclusions Lung protective ventilation strategy combining lung recruitment maneuver can significantly improve the oxygenation in patients with severe burn complicated with ARDS and may therefore improve the prognosis.