CAJ | 학술논문

俯卧位通气对合并间质性肺病的急性呼吸窘迫综合征患者呼吸动力学和预后的影响
부와위통기대합병간질성폐병적급성호흡군박종합정환자호흡동역학화예후적영향
Effect of prone position ventilation on respiratory mechanics and prognosis in patients with acute respiratory distress syndrome concurrent with interstitial lung disease

万方数据

中华危重病急救医学中華危重病急救醫學 중화위중병급구의학
Chinese Critical Care Medicine
2015年 10期 785-790 ,共6页

孙庆文%朱满桂%席寅%余裕恒%刘学松%桑岭%徐永昊%陈思蓓%农凌波%何为群%徐远达%黎毅敏%刘晓青

손경문%주만계%석인%여유항%류학송%상령%서영호%진사배%농릉파%하위군%서원체%려의민%류효청

俯卧位通气%间质性肺病%急性呼吸窘迫综合征%呼吸动力学俯臥位通氣%間質性肺病%急性呼吸窘迫綜閤徵%呼吸動力學
부와위통기%간질성폐병%급성호흡군박종합정%호흡동역학
Prone position ventilation%Interstitial lung disease%Acute respiratory distress syndrome%Respiratory mechanics

目的：探讨俯卧位通气（PPV）对合并间质性肺病（ILD）的急性呼吸窘迫综合征（ARDS）患者呼吸动力学和预后的影响。方法回顾性分析2013年2月至2015年1月广州医科大学附属第一医院重症医学科收治的进行PPV治疗的36例重度ARDS患者的临床资料，按是否伴ILD分为两组。比较两组患者每次PPV前后以及PPV整体治疗前后呼吸动力学与氧合指标的变化，应用Kaplan-Meier方法绘制两组患者60 d生存曲线。结果36例重度ARDS患者中伴有ILD 17例。① ILD组与无ILD组患者基线资料差异均无统计学意义。②每次PPV前后呼吸动力学与氧合指标比较：与PPV前比较，有无ILD两组PPV后氧合指数（PaO2/FiO2， mmHg，1 mmHg＝0.133 kPa）均显著改善〔ILD组：132.0（93.5，172.0）比118.7（92.0，147.8），无ILD组：126.1（100.9，170.0）比109.2（89.0，135.0），均P＜0.05〕；ILD组PPV后呼气末正压（PEEP，cmH2O，1 cmH2O＝0.098 kPa）明显上升〔10.0（10.0，12.0）比10.0（9.2，12.0），P＜0.05〕；无ILD组PPV后呼吸频率（RR，次/min）明显减慢〔24.5（22.0，27.0）比25.5（22.8，28.0），P＜0.05〕。无ILD组PPV后动态呼吸系统顺应性（Crs，mL/cmH2O）较ILD组下降〔19.7（16.1，28.6）比23.0（19.0，29.7），P＜0.05〕。③PPV整体治疗前后的呼吸动力学与氧合指标比较：无ILD组PPV治疗结束后PaO2/FiO2（mmHg）较开始PPV治疗前明显增加〔135.0（86.0，200.0）比97.4（69.2，127.5），P＜0.05〕，且明显高于ILD组PPV治疗结束后〔135.0（86.0，200.0）比78.7（59.3，114.9）， P＜0.05〕。无ILD组和ILD组患者开始PPV治疗前Crs（mL/cmH2O）差异无统计学意义〔24.3（15.9，48.9）比18.9（12.7，27.3），P＞0.05〕；治疗结束后Crs均呈下降趋势，但差异均无统计学意义〔无ILD组：22.7（15.2，27.1）比24.3（15.9，48.9），ILD组：16.2（12.8，25.6）比18.9（12.7，27.3），均P＞0.05〕。④ ILD组患者60 d病死率明显高于无ILD组〔88.2%（15/17）比57.9%（11/19），P＝0.047〕；Kaplan-Meier生存曲线显示：ILD组60 d生存率明显低于无ILD组（χ2＝5.658，P＝0.017）。结论 PPV能改善重度ARDS患者的氧合，对伴有ILD的ARDS患者，PPV时虽然顺应性略有改善，但远期疗效较无ILD的患者差。
목적：탐토부와위통기（PPV）대합병간질성폐병（ILD）적급성호흡군박종합정（ARDS）환자호흡동역학화예후적영향。방법회고성분석2013년2월지2015년1월엄주의과대학부속제일의원중증의학과수치적진행PPV치료적36례중도ARDS환자적림상자료，안시부반ILD분위량조。비교량조환자매차PPV전후이급PPV정체치료전후호흡동역학여양합지표적변화，응용Kaplan-Meier방법회제량조환자60 d생존곡선。결과36례중도ARDS환자중반유ILD 17례。① ILD조여무ILD조환자기선자료차이균무통계학의의。②매차PPV전후호흡동역학여양합지표비교：여PPV전비교，유무ILD량조PPV후양합지수（PaO2/FiO2， mmHg，1 mmHg＝0.133 kPa）균현저개선〔ILD조：132.0（93.5，172.0）비118.7（92.0，147.8），무ILD조：126.1（100.9，170.0）비109.2（89.0，135.0），균P＜0.05〕；ILD조PPV후호기말정압（PEEP，cmH2O，1 cmH2O＝0.098 kPa）명현상승〔10.0（10.0，12.0）비10.0（9.2，12.0），P＜0.05〕；무ILD조PPV후호흡빈솔（RR，차/min）명현감만〔24.5（22.0，27.0）비25.5（22.8，28.0），P＜0.05〕。무ILD조PPV후동태호흡계통순응성（Crs，mL/cmH2O）교ILD조하강〔19.7（16.1，28.6）비23.0（19.0，29.7），P＜0.05〕。③PPV정체치료전후적호흡동역학여양합지표비교：무ILD조PPV치료결속후PaO2/FiO2（mmHg）교개시PPV치료전명현증가〔135.0（86.0，200.0）비97.4（69.2，127.5），P＜0.05〕，차명현고우ILD조PPV치료결속후〔135.0（86.0，200.0）비78.7（59.3，114.9）， P＜0.05〕。무ILD조화ILD조환자개시PPV치료전Crs（mL/cmH2O）차이무통계학의의〔24.3（15.9，48.9）비18.9（12.7，27.3），P＞0.05〕；치료결속후Crs균정하강추세，단차이균무통계학의의〔무ILD조：22.7（15.2，27.1）비24.3（15.9，48.9），ILD조：16.2（12.8，25.6）비18.9（12.7，27.3），균P＞0.05〕。④ ILD조환자60 d병사솔명현고우무ILD조〔88.2%（15/17）비57.9%（11/19），P＝0.047〕；Kaplan-Meier생존곡선현시：ILD조60 d생존솔명현저우무ILD조（χ2＝5.658，P＝0.017）。결론 PPV능개선중도ARDS환자적양합，대반유ILD적ARDS환자，PPV시수연순응성략유개선，단원기료효교무ILD적환자차。
ObjectiveTo explore the effect of prone position ventilation (PPV) on respiratory mechanics and prognosis in patients with acute respiratory distress syndrome (ARDS) concurrent with interstitial lung disease (ILD). Methods The data of 36 severe ARDS patients admitted to Department of Critical Care Medicine of the First Affiliated Hospital of Guangzhou Medical University from February 2013 to January 2015, were retrospectively analyzed. They were then divided into two groups according to the presence of ILD or not. The changes in respiratory mechanics and oxygenation indexes were compared before and after PPV treatment in all the patients. Kaplan-Meier method was applied to draw the 60-day survival curves of both groups.Results There were 17 cases with ILD among these 36 severe ARDS patients.① No significant difference was found in baseline data between ILD group and non-ILD group.② Respiratory mechanics and oxygenation pre-PPV and post-PPV: compared with pre-PPV, oxygenation index (PaO2/FiO2, mmHg, 1 mmHg = 0.133 kPa) post-PPV was significantly increased in both groups [ILD group : 132.0 (93.5, 172.0) vs. 118.7 (92.0, 147.8); non-ILD group: 126.1 (100.9, 170.0) vs. 109.2 (89.0, 135.0), bothP< 0.05]. Compared with pre-PPV, positive end-expiratory pressure (PEEP, cmH2O,1 cmH2O = 0.098kPa) post-PPV was significantly higher in ILD group [10.0 (10.0, 12.0) vs. 10.0 (9.2, 12.0),P< 0.05], and respiratory rate (RR, times/min) was significantly lower in non-ILD group [24.5 (22.0, 27.0) vs. 25.5 (22.8, 28.0),P< 0.05]. The compliance of the respiratory system (Crs, mL/cmH2O) post-PPV in non-ILD group was significantly lower than that of the ILD group [19.7 (16.1, 28.6) vs. 23.0 (19.0, 29.7),P< 0.05].③ Respiratory mechanics and oxygenation pre-PPV and post-PPV in total: after all the PPV therapy, PaO2/FiO2 (mmHg) was significantly increased in non-ILD group [135.0 (86.0, 200.0) vs. 97.4 (69.2, 127.5), P< 0.05], PaO2/FiO2 after all the PPV therapy in non-ILD group was also higher than that in ILD group [135.0 (86.0, 200.0) vs. 78.7 (59.3, 114.9),P< 0.05]. No significant difference in Crs (mL/cmH2O) before PPV treatment was found between non-ILD and ILD groups [24.3 (15.9, 48.9) vs. 18.9 (12.7, 27.3),P> 0.05], and Crs was lower after PPV treatment in both groups, but without significant difference [non-ILD group: 22.7 (15.2, 27.1) vs. 24.3 (15.9, 48.9); ILD group: 16.2 (12.8, 25.6) vs. 18.9 (12.7, 27.3), bothP> 0.05].④ The 60-day mortality in ILD group was significantly higher than that in non-ILD group [88.2% (15/17) vs. 57.9% (11/19),P = 0.047). It was shown by Kaplan-Meier curves that 60-day survival patients in ILD group was significantly lower than those in non-ILD group (χ2 = 5.658,P = 0.017). Conclusions PPV can improve oxygenation in severe ARDS. Compared with non-ILD group, though the compliance of respiratory system in ILD group is increased during PPV, long-term effect is better in non-ILD group.