中华急诊医学杂志
中華急診醫學雜誌
중화급진의학잡지
CHINESE JOURNAL OF EMERGENCY MEDICINE
2014年
9期
1006-1012
,共7页
肺复张%呼气末正压%急性呼吸窘迫综合征
肺複張%呼氣末正壓%急性呼吸窘迫綜閤徵
폐복장%호기말정압%급성호흡군박종합정
Lung recruitment%Positive end-expiratory pressure%Acute respiratory distress syndrome
目的 分析24例接受机械通气的甲型H1N1流感病毒性肺炎致ARDS患者的临床资料,探讨压力控制通气(PCV)联合间断高PEEP法肺复张的疗效及其影响因素.方法 以2009年10月至2010年2月中国医科大学附属第一医院急诊监护室(EICU)救治的24例接受机械通气的甲型H1N1流感病毒性肺炎所致ARDS患者为研究对象,均经口气管插管按照肺保护性通气策略应用PCV模式进行机械通气,当脉搏血氧饱和度(SpO2)持续低于88％超过30 min时,在原通气模式下增加PEEP至30 cmH2O(1 cmH2O =0.098 kPa)持续60 s进行肺复张,记录操作前、操作时、操作后30min内的呼吸机监测参数和患者平均动脉压、心率、SpO2等的变化,观察操作后SpO2最高值(SpO2max)、最低值(SpO2max)及其出现时间.复张操作后15 min内SpO2升高≥3％为复张有效.分析比较肺复张前后患者血流动力学和呼吸力学等指标.结果 24例患者中存活16例,死亡8例,在EICU接受机械通气时间3.5～12 d,中位数5.5d,期间肺复张操作158例次,有效76例次(48.1％),存活组复张有效的比例与死亡组比较差异有统计学意义(66.2％ vs.33.3％,x2=16.91,P＜0.01).与复张前比较,复张操作后患者心率增加(92.6±11.8)次/min vs.(73.O±12.6)次/min,t=2.12,P=0.038; MAP降低(66.1±9.3)mmHg vs.(73.9 ±11.4) mmHg(1 mmHg =0.133kPa),t=1.98,P=0.049.85.9％的患者(134例次)复张操作后SpO2较操作前下降,SpO2min出现时间在复张操作后(2.1±0.6)min,有效组复张操作后SpO2 max较操作前增加(6.9±1.6)％,SpO2max出现时间在操作后(12.7±2.6)min.有效组肺复张操作后30 min SpO2较操作前增加(90.4±4.4)％vs.(86.7±7.6)％,t=2.01,P=0.047.有效组复张操作前平均PEEP水平低于无效组(8.6±3.4) cmH2Ovs.(11.3±4.2) cmH2O,t=2.24,P=0.028;平均机械通气时间短于无效组(4.1±3.1)d vs.(5.8±2.5)d,t=2.58,P=0.011;胸廓动态顺应性较高(30.8±6.2)mL/cmH2Ovs.(26.1±5.1)mL/cmH2O,t=2.12,P=0.038.结论 30 cmH2O的PEEP持续60 s肺复张方法可引起甲型H1N1流感病毒性肺炎所致ARDS患者短暂血流动力学改变,其效果可能与复张前PEEP水平、机械通气时间和胸廓动态顺应性有关.
目的 分析24例接受機械通氣的甲型H1N1流感病毒性肺炎緻ARDS患者的臨床資料,探討壓力控製通氣(PCV)聯閤間斷高PEEP法肺複張的療效及其影響因素.方法 以2009年10月至2010年2月中國醫科大學附屬第一醫院急診鑑護室(EICU)救治的24例接受機械通氣的甲型H1N1流感病毒性肺炎所緻ARDS患者為研究對象,均經口氣管插管按照肺保護性通氣策略應用PCV模式進行機械通氣,噹脈搏血氧飽和度(SpO2)持續低于88％超過30 min時,在原通氣模式下增加PEEP至30 cmH2O(1 cmH2O =0.098 kPa)持續60 s進行肺複張,記錄操作前、操作時、操作後30min內的呼吸機鑑測參數和患者平均動脈壓、心率、SpO2等的變化,觀察操作後SpO2最高值(SpO2max)、最低值(SpO2max)及其齣現時間.複張操作後15 min內SpO2升高≥3％為複張有效.分析比較肺複張前後患者血流動力學和呼吸力學等指標.結果 24例患者中存活16例,死亡8例,在EICU接受機械通氣時間3.5～12 d,中位數5.5d,期間肺複張操作158例次,有效76例次(48.1％),存活組複張有效的比例與死亡組比較差異有統計學意義(66.2％ vs.33.3％,x2=16.91,P＜0.01).與複張前比較,複張操作後患者心率增加(92.6±11.8)次/min vs.(73.O±12.6)次/min,t=2.12,P=0.038; MAP降低(66.1±9.3)mmHg vs.(73.9 ±11.4) mmHg(1 mmHg =0.133kPa),t=1.98,P=0.049.85.9％的患者(134例次)複張操作後SpO2較操作前下降,SpO2min齣現時間在複張操作後(2.1±0.6)min,有效組複張操作後SpO2 max較操作前增加(6.9±1.6)％,SpO2max齣現時間在操作後(12.7±2.6)min.有效組肺複張操作後30 min SpO2較操作前增加(90.4±4.4)％vs.(86.7±7.6)％,t=2.01,P=0.047.有效組複張操作前平均PEEP水平低于無效組(8.6±3.4) cmH2Ovs.(11.3±4.2) cmH2O,t=2.24,P=0.028;平均機械通氣時間短于無效組(4.1±3.1)d vs.(5.8±2.5)d,t=2.58,P=0.011;胸廓動態順應性較高(30.8±6.2)mL/cmH2Ovs.(26.1±5.1)mL/cmH2O,t=2.12,P=0.038.結論 30 cmH2O的PEEP持續60 s肺複張方法可引起甲型H1N1流感病毒性肺炎所緻ARDS患者短暫血流動力學改變,其效果可能與複張前PEEP水平、機械通氣時間和胸廓動態順應性有關.
목적 분석24례접수궤계통기적갑형H1N1류감병독성폐염치ARDS환자적림상자료,탐토압력공제통기(PCV)연합간단고PEEP법폐복장적료효급기영향인소.방법 이2009년10월지2010년2월중국의과대학부속제일의원급진감호실(EICU)구치적24례접수궤계통기적갑형H1N1류감병독성폐염소치ARDS환자위연구대상,균경구기관삽관안조폐보호성통기책략응용PCV모식진행궤계통기,당맥박혈양포화도(SpO2)지속저우88％초과30 min시,재원통기모식하증가PEEP지30 cmH2O(1 cmH2O =0.098 kPa)지속60 s진행폐복장,기록조작전、조작시、조작후30min내적호흡궤감측삼수화환자평균동맥압、심솔、SpO2등적변화,관찰조작후SpO2최고치(SpO2max)、최저치(SpO2max)급기출현시간.복장조작후15 min내SpO2승고≥3％위복장유효.분석비교폐복장전후환자혈류동역학화호흡역학등지표.결과 24례환자중존활16례,사망8례,재EICU접수궤계통기시간3.5～12 d,중위수5.5d,기간폐복장조작158례차,유효76례차(48.1％),존활조복장유효적비례여사망조비교차이유통계학의의(66.2％ vs.33.3％,x2=16.91,P＜0.01).여복장전비교,복장조작후환자심솔증가(92.6±11.8)차/min vs.(73.O±12.6)차/min,t=2.12,P=0.038; MAP강저(66.1±9.3)mmHg vs.(73.9 ±11.4) mmHg(1 mmHg =0.133kPa),t=1.98,P=0.049.85.9％적환자(134례차)복장조작후SpO2교조작전하강,SpO2min출현시간재복장조작후(2.1±0.6)min,유효조복장조작후SpO2 max교조작전증가(6.9±1.6)％,SpO2max출현시간재조작후(12.7±2.6)min.유효조폐복장조작후30 min SpO2교조작전증가(90.4±4.4)％vs.(86.7±7.6)％,t=2.01,P=0.047.유효조복장조작전평균PEEP수평저우무효조(8.6±3.4) cmH2Ovs.(11.3±4.2) cmH2O,t=2.24,P=0.028;평균궤계통기시간단우무효조(4.1±3.1)d vs.(5.8±2.5)d,t=2.58,P=0.011;흉곽동태순응성교고(30.8±6.2)mL/cmH2Ovs.(26.1±5.1)mL/cmH2O,t=2.12,P=0.038.결론 30 cmH2O적PEEP지속60 s폐복장방법가인기갑형H1N1류감병독성폐염소치ARDS환자단잠혈류동역학개변,기효과가능여복장전PEEP수평、궤계통기시간화흉곽동태순응성유관.
Objective To investigate the clinical factors dominant in the efficacy of lung recruitment maneuver (RM) with high-level positive end-expiratory pressure (PEEP) under pressure control ventilation in patients with 2009 influenza A (H1N1)-associated acute respiratory distress syndrome (ARDS) by analyzing the clinical data of 24 patients treated with mechanical ventilation.Methods A retrospective study was carried out in a 16-bed capacity emergency intensive care unit (EICU) of the First Affiliated Hospital of China Medical University from October 2009 to January 2010.Twenty-four patients with influenza-associated ARDS were included.During pressure control ventilation,when SpO2 persisted lower than 88％ for more than 30 min,RM with high-level PEEP was initiated to normalize lung volume at 30 cmH2O for 60 s.The RM was responded as SpO2 increased more than 3％ within 15 min; otherwise,the increase below 3％ in SpO2 would be considered non-responded.Variations in respiratory mechanics,oxygen metabolism and hemodynamic parameters were measured before and after RM.Results Of 24 patients with influenza-associated ARDS,16 survived and 8 deceased.The median duration of mechanical ventilation (DMV) in EICU was 5.5 days (range from 3.5 to 12.0 days).During the entire study period,a total of 158 RMs with high-level PEEP were done,including 76 (48.1％) responded RMs (the responded group) and 82 (51.9％) non-responded RMs (the non-responded group).In survivor group,the ratio of effective RM was higher than in nonsurvivors group (66.2％ vs.33.3％,P ＜ 0.01).Compared with the data before RM,HR was increased (92.6 ± 11.8) vs.(73.0 ± 12.6),P =0.038 and MAP was decreased (66.1 ±9.3) mmHg vs.(73.9 ± 11.4) mmHg,P=0.049 during RM,and these difference were not statistically significant at 3 min after RM.The decrease in SpO2 after 134 procedures of RMs in 85.9％ patients,and the minimum value of SpO2 occurred at (2.1 ±0.6) min after RM.In the responded group,the maximum SpO2 were higher than that before RM by (6.9 ± 1.6) ％ occurred at (12.7 ±2.6) min after RM.Compared with the data before RM,SpO2 were increased (90.4 ± 4.4) ％ vs.(86.7 ± 7.6) ％,P =0.047) in responded group at 30 min after RM.The initial PEEP level in the responded group was lower than that of the non-responded group (8.6 ± 3.4) cmH2O vs.(11.3 ±4.2) cmH2O,P=0.028.The initial mean DMV in the responded group was also shorter than that in the non-responded group (4.1 ± 3.1) d vs.(5.8 ± 2.5) d,P =0.011.Furthermore,the initial dynamic lung-thorax compliance (Cdyn) was obviously higher in the responded group than that in the non-responded group (30.8 ±6.2) mL/cmH2O vs.(26.1 ±5.1) mL/cmH2O,P=0.038.Conclusion The lung RM with high-level PEEP may cause temporary hemodynamic changes and the initial PEEP level,DMV,and Cdyn may be potential factors influencing the efficacy of lung RM.
