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目的探讨急性呼吸窘迫综合征(ARDS)患者小潮气量肺保护性通气之上,进一步减轻呼吸机相关性肺损伤及改善患者预后的方法。方法北京协和医院加强医疗科2004年7月至2005年6月30例ARDS患者,根据随机表分为小潮气量组(LTV组,14例)和个体化通气组(Ⅳ组, 16例)。其中LTV组采用6 ml／kg的潮气量及高呼气末正压(PEEP)治疗策略。而IV组以监测静态压力容积(P-V)曲线为基础设定参数,以呼气相曲线参数b为PEEP,结合吸气相曲线高位转折点并限制潮气量≤8 ml／kg,用吸气相和呼气相参数b的差值(Ab)评估肺复张潜能并指导肺复张操作。比较两种通气策略对患者临床疗效、肺损伤程度以及预后等方面的影响。结果Ⅳ组28 d患者病死率(35．7％)与LTV组(57．2％)比较差异无统计学意义(X2=1．265,P>0．05)。Ⅳ组患者第3天和第7天的血浆表面活性蛋白D(SP-D)水平[154(91～217)、149(91～206)mg／L]与入组前[140(80～200)mg／L]比较差异无统计学意义(Z分别为1．079、1．741,P均>0．05);而第3天和第7天的白细胞介素8(IL-8)表达[179(122～236)、210(100～321)ng／L]与入组前[210(132～289)ng／L]比较差异亦无统计学意义(Z分别为-0．879、0．471,P均>0．05)。Ⅳ组患者28 d内脱离ICU时间[11(5～16)d]显著高于LTV组[3(0～8)d,Z=-2．277,P<0．05];无肺外器官衰竭时间[13(6～18)d]亦显著高于LTV组[3(0～7)d,Z=-2．372,P<0．05]。Ⅳ组患者前3 d PEEP水平,潮气量,动脉血二氧化碳分压(PaCO2)、气道平台压力(Pplat)[(11±2)cm H2O(1 cm H2O=0．098 kPa),(511±66)ml, (37±5)mm Hg(1 mm Hg=0．133 kPa),(21±5)cm H2O]与LTV组[(16±3)cm H2O,(407±58)ml, (47±8)mm Hg,(26±4)cm H2O]比较差异均有统计学意义(t分别为-8．019、6．501、-4．311、-4．823,P均<0．01)。结论个体化通气治疗与小潮气量高PEEP通气策略相比,更适合患者呼吸力学特征,可减少不必要的PEEP应用,改善顺应性,避免CO2潴留;可避免血SP-D及IL-8的升高而保护肺功能;并可延长28 d内脱离ICU的时间和无肺外器官衰竭时间,具有更佳的临床应用前景。
Objective To investigate the protective effect of low-tidal volume pneumoconiosis ventilation on patients with acute respiratory distress syndrome (ARDS), to further reduce the ventilator-associated lung injury and to improve the prognosis of patients. Methods Beijing Union Medical College Hospital to strengthen the medical treatment of July 2004 to June 2005 30 cases of ARDS patients were randomly divided into small tidal volume (LTV group, 14 cases) and individual ventilation group (Ⅳ group, 16 cases). In LTV group, the tidal volume of 6 ml / kg and PEEP treatment strategy were used. While group IV set the parameters based on the monitoring of static pressure volume (PV) curve. The parameter of the expiratory curve b was PEEP, which combined with the high turning point of the inspiratory phase curve and the limit of tidal volume ≤8 ml / kg. The difference in expiratory phase parameter b (Ab) is used to assess the potential for lung recruitment and to guide pulmonary recruitment. The effects of two ventilation strategies on the clinical efficacy, degree of lung injury and prognosis were compared. Results The case-fatality rate (35.7%) of the 28th day in the Ⅳ group was not significantly different from that of the LTV group (57.2%) (X2 = 1.265, P> 0.05). The levels of plasma surfactant protein D (SP-D) at day 3 and day 7 in group Ⅳ were significantly higher than those in group before enrollment [140 (80 ~ 200 ) mg / L], there was no significant difference between the two groups (Z = 1.079 and 1.741 respectively, P> 0.05), while the expression of IL-8 on the 3rd and 7th day There was no significant difference between the two groups ([179 (122 ~ 236), 210 (100 ~ 321) ng / L] .471, P> 0.05). In group Ⅳ, the time from ICU within 28 days [11 (5-16) d] was significantly higher than that in LTV group [3 (0-8) d, Z = -2.277, P <0.05] The failure time [13 (6-18) d] was also significantly higher than that in the LTV group [3 (0-7) d, Z = -2.372, P <0.05]. The levels of PEEP, tidal volume, PaCO2, Pplat [(11 ± 2) cm H2O (1 cm H2O = 0.098 kPa), (511 ± (37 ± 5) mmHg, (21 ± 5) cm H2O and (16 ± 3) cm H2O, (407 ± 58) ml, 47 ± 8 mm Hg and 26 ± 4 cm H 2 O], respectively (t = -8.019, 6.501, -4.311, -4.823, respectively, P <0. 01). Conclusions Individualized ventilation is more suitable for patients with respiratory mechanics than PEEP with low tidal volume. It can reduce unnecessary PEEP, improve compliance and avoid CO2 retention. It can avoid the rise of blood SP-D and IL-8 High and protect the lung function; and can extend the time from the ICU within 28 days and no extrapulmonary organ failure time, with better clinical application prospects.