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背景:肺保护性通气策略和呼气末正压作为近些年来治疗急性呼吸窘迫综合征(acuterespiratorydistresssyndrome,ARDS)有效通气方式在临床得到广泛的应用,但对其疗效一直有很大的争议。目的:观察在肺保护性通气条件下ARDS模型犬氧合指数以及外周血和肺不同部位(肺上区、肺下区腹侧和肺下区背侧)支气管肺泡灌洗液中炎性递质的变化。设计:随机对照动物实验。单位:解放军总医院呼吸科。材料:取健康成年雄性杂种犬24只,单纯随机分为肺内源性ARDS实验组、肺内源性ARDS对照组、肺外源性ARDS实验组和肺外源性ARDS对照组,每组6只。方法:采用静脉注射油酸0.1～0.15mg/kg形成肺外源性ARDS动物模型;应用十六烷磺基丁二酸钠盐气管内吸入形成肺内源性ARDS动物模型。实验组肺损伤后进行肺保护性通气(潮气量:8mL/kg,呼气末正压:0.981kPa)3h,对照组继续进行大潮气通气(潮气量:14～17mL/kg,呼气末正压:0kPa)3h。主要观察指标:①各组犬氧合指数的变化。②动态观察肺保护性通气条件下各组犬外周血和肺不同部位(肺尖叶、肺心叶和肺膈叶)支气管肺泡灌洗液中炎性递质(肿瘤坏死因子α,白细胞介素1β和白细胞介素6)的变化。结果:24只犬全部进入结果分析。①肺损伤后各组犬氧合指数均显著下降,应用肺保护性通气治疗后实验组氧合指数明显高于对照组(P<0.05);肺保护性通气后2h和3h肺外源性ARDS实验组氧合指数明显高于肺内源性ARDS实验组(P<0.05)。②肺损伤后各组外周血中炎性递质明显升高,应用肺保护性通气治疗后,炎性递质水平有不同度下降,但肺内源性ARDS实验组的治疗效果不如肺外源性ARDS实验组。③肺内源性ARDS模型犬肺尖叶和肺心叶支气管肺泡灌洗液中炎性递质水平明显高于肺外源性ARDS模型犬。结论:肺外源性和肺内源性急性呼吸窘迫综合征模型犬肺的不同部位炎性递质释放和氧合指数改善均具有明显的差异,而肺保护性通气模式对肺外源性急性呼吸窘迫综合征模型犬具有良好的效果,对肺内源性急性呼吸窘迫综合征模型犬疗效较差。
BACKGROUND: Pulmonary protective ventilation strategy and positive end-expiratory pressure have been widely used in clinical practice as an effective ventilation method for the treatment of acute respiratory distress syndrome (ARDS) in recent years. However, there has been controversy about its efficacy. OBJECTIVE: To observe the oxygenation index of ARDS model dogs in lungs with protective ventilation and the levels of inflammatory neurotransmitter in bronchoalveolar lavage fluid in different regions of the peripheral blood and lungs (upper pulmonary region, lower pulmonary region and lower lung region) The change. Design: Randomized controlled animal experiments. Unit: PLA General Hospital Department of Respiratory. MATERIALS: Twenty-four healthy adult male hybrid dogs were randomly divided into experimental group of ARDS, endogenous ARDS group, exogenous ARDS group and ARDS group only. Methods: Acute pulmonary ARDS animal model was established by intravenous injection of 0.1-0.15 mg / kg oleic acid. The animal model of endogenous ARDS was established by tracheal inhalation of sodium cetyl sulfosuccinate. Pulmonary protective ventilation (tidal volume: 8 mL / kg, positive end expiratory pressure: 0.981 kPa) for 3 h after lung injury in the experimental group was continued for 3 h. The control group continued to undergo large tidal ventilation (tidal volume: 14-17 mL / kg, Pressure: 0kPa) 3h. MAIN OUTCOME MEASURES: ① Changes of dog’s oxygenation index. ② Dynamic observation of inflammatory mediators (TNF-α, IL-1β) in bronchoalveolar lavage fluid of peripheral blood and lungs in different groups of dogs (lung, lung, heart and lung) 1β and interleukin 6). Results: All 24 dogs entered the result analysis. ① The oxygenation index of dogs in each group decreased significantly after lung injury. The oxygenation index of experimental group was significantly higher than that of the control group after lung protective ventilation (P <0.05). The lung-derived ARDS The oxygenation index of the experimental group was significantly higher than that of the pulmonary endogenous ARDS experimental group (P <0.05). ②The levels of inflammatory neurotransmitters in the peripheral blood of each group were significantly increased after lung injury. The levels of inflammatory neurotransmitters decreased with the use of protective ventilation, but the therapeutic effect of endogenous ARDS was not as good as that of lung ARDS experimental group. ③ The levels of inflammatory mediators in lung apical and bronchial alveolar lavage fluid of endogenous ARDS models were significantly higher than those of exogenous ARDS model lungs. CONCLUSIONS: There are significant differences in the release of inflammatory neurotransmitters and the improvement of oxygenation index in different parts of the lung of exogenous and endogenous acute respiratory distress syndrome in lungs. However, Respiratory distress syndrome model dogs have a good effect, poor efficacy of the lung endogenous acute respiratory distress syndrome model dogs.