-
急性呼吸窘迫综合征(ARDS)是急性呼吸衰竭最常见的类型,其病死率仍居高不下[1-2]。机械通气是ARDS主要的支持治疗手段,由于ARDS存在肺泡塌陷和肺损伤不均一性,不当的机械通气可导致不同区域肺泡萎陷和过度膨胀,研究[3-4]显示小潮气量(VT)通气能够降低ARDS病人的病死率。由于部分中重度ARDS病人存在更多的肺泡塌陷;研究[5]显示,即使采用6 mL/kg.IBW(.IBW为以理想体质量计算)VT通气,仍有病人存在肺泡过度膨胀,肺泡灌洗液炎症介质表达水平明显升高。有研究[6-7]将这部分病人的VT进一步降低可减少肺泡过度膨胀,减轻肺损伤。而对于肺顺应性≥0.6 mL·cmH2O-1·kg-1的ARDS病人[4],小VT通气并不能进一步降低肺应变,而且可能出现肺不张、镇静剂用量增加等不良反应[8]。因此,ARDS病人VT的设置需考虑肺泡塌陷程度和呼气末肺容积。肺应变是VT与呼气末肺容积的比值[9],对于高肺应变(>0.27)机械通气的ARDS病人,其肺内炎症介质的表达明显高于低应变病人,且肺应变大小与肺内炎症介质的表达水平显著相关[10]。因此,同一VT并不适合所有ARDS病人,将应变用于指导ARDSVT的设置可能更合理。本研究以机械通气的ARDS病人为研究对象,观察不同VT对ARDS病人肺损伤的影响。现作报道。
-
行机械通气的ARDS病人19例,C≥0.6组9例,C < 0.6组10例。C≥0.6组在VT=12 mL/kg.IBW时有1例病人因Pplat≥30 cmH2O而终止实验,C < 0.6组在VT=8 mL/kg.IBW、10 mL/kg.IBW、12 mL/kg.IBW时共有1例、6例、8例病人因Pplat≥30 cmH2O而终止实验。2组病人性别、年龄、PaO2/FiO2、APACHEⅡ评分、Murray评分等差异无统计学意义(P>0.05);在基础机械通气情况下PEEP、VT差异无统计学意义(P>0.05),C、FRC、EELV、肺应变差异有统计学意义(P < 0.01)(见表 1)。随着呼吸系统顺应性的增加,EELV逐渐增加,且两者呈显著正相关关系(r=0.488,P < 0.05)。
分组 n 男性 年龄/岁 IBW/kg APACHE Ⅱ/分 Murray评分/分 (PaO2/FiO2)/mmHg VT/(mL/kg.IBW) PEEP/cmH2O FRC/mL EELV/mL C/mL·cmH2O-1·kg-1 肺应变 C≥0.6 9 7 71±12 65.4±7.9 18.6±8.3 2.2±0.4 212±69 6.7±1.1 8.3±1.6 1 905±732 2 546±1 024 0.83±0.20 0.19±0.08 C < 0.6 10 6 68±17 64.4±7.0 19.9±5.6 2.6±0.6 189±103 6.5±1.3 8.1±1.9 943±589 1 267±689 0.49±0.07 0.42±0.20 t — — 0.44 0.29 0.40 1.69 0.56 0.36 0.25 3.17 3.23 5.06 3.22 P — >0.05* >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 < 0.01 < 0.01 < 0.01 < 0.01 *示Fisher确切概率 表 1 病人的一般情况比较(x±s)
-
随着VT的增加,Ppeak和Pplat均逐渐增加,Pplat均≤30 cmH2O。与6 mL/kg.IBWVT相比,8 mL/kg.IBW、10 mL/kg.IBW和12 mL/kg.IBWVT的Pplat差异均有统计学意义(P < 0.05)。与C≥0.6组病人相比,C < 0.6组病人的Pplat在不同VT下均明显升高(P < 0.05~P < 0.01),PEEP差异无统计学意义(P>0.05)(见表 2)。
分组 n 基础设置 6 8 10 12 F P MS组内 PEEP/cmH2O C≥0.6 9 8.3±1.6 8.3±1.6 8.3±1.6 8.3±1.6 8.1±1.6 0.03 >0.05 2.560 C < 0.6 10 8.1±1.9 8.1±1.9 8.1±2.0 8.1±2.0 8.1±2.0 0.00 >0.05 3.844 T — 0.25 0.25 0.24 0.24 0.24 — — — P — >0.05 >0.05 >0.05 >0.05 >0.05 — — — Ppeak/cmH2O C≥0.6 9 21.6±4.4 20.1±4.4 24.4±4.0 31.3±5.7* 34.9±4.9* 16.48 < 0.01 366.712 C < 0.6 10 27.1±4.1 27.1±3.9 31.0±4.9 33.9±4.9* 35.6±5.3* 6.93 < 0.01 149.901 t — 2.82 3.68 3.19 1.07 0.30 — — — P — < 0.05 < 0.01 < 0.01 >0.05 >0.05 — — — Pplat/cmH2O C≥0.6 9 16.9±3.0 15.7±2.5 19.3±2.5* 22.3±3.1* 24.4±2.3* 16.33 < 0.01 118.921 C < 0.6 10 21.4±2.9 21.8±2.6 25.6±4.1 26.7±3.2* 27.6±2.6* 8.29 < 0.01 81.221 t — 3.32 5.20 3.99 3.09 2.83 — — — P — < 0.01 < 0.01 < 0.01 < 0.01 < 0.05 — — — 注:与VT= 6 mL/kg.IBW比较*P < 0.05 表 2 不同VT对ARDS病人气道压力的影响(x±s; mL/kg·IBW)
-
当VT由6 mL/kg.IBW逐渐增加至12 mL/kg.IBW时,EELV差异无统计学意义(P>0.05),但C < 0.6组病人较C≥0.6组病人在6 mL/kg.IBW及8 mL/kg.IBWVT通气时的EELV降低(P < 0.05和P < 0.01);与C≥0.6组病人相比,C < 0.6组病人呼吸系统顺应性明显降低(P < 0.05)(见表 3)。随着VT的增加,肺应变由(0.31±0.27)逐渐增加至(0.52±0.46),且肺应变与VT呈显著正相关关系(相关系数为0.978,P < 0.01)。肺应变≥0.27的病人比例呈增加趋势,但各VT下肺应变≥0.27的病人比例差异无统计学意义(P>0.05)(见表 3)。
分组 n 6 8 10 12 F P MS组内 C/mL·cmH2O-1·kg-1 C≥0.6 9 0.85±0.23 0.75±0.14 0.70±0.11 0.73±0.10 1.61 >0.05 0.038 C < 0.6 10 0.45±0.08 0.40±0.16 0.48±0.10 0.47±0.09 1.01 >0.05 0.013 t — 5.18 5.05 4.57 5.97 — — — P — < 0.01 < 0.01 0.01 < 0.01 — — — EELV/mL C≥0.6 9 2 804±1 562 2 717±1 124 2 628±1 086 2 534±1 048 0.08 >0.05 121268.000 C < 0.6 10 1 317±775 1 347±886 1 860±1 323 1 482±1 230 0.54 >0.05 622710.000 t — 2.67 2.97 1.37 1.20 — — — P — < 0.05 < 0.01 >0.05 >0.05 — — — 肺应变 C≥0.6 9 0.17±0.08 0.22±0.09 0.28±0.11 0.36±0.17* 4.34 < 0.05 0.060 C < 0.6 10 0.44±0.32 0.64±0.61 0.67±0.60 0.67±0.59 0.42 >0.05 0.123 t — 2.46 2.04 1.92 1.52 — — — P — < 0.05 >0.05 >0.05 >0.05 — — — 肺应变≥0.27 C≥0.6 9 11.1 22.2 44.4 62.5 — — — C < 0.6 10 60.0 77.8 88.9 88.9 — — — z — 2.21 2.52 2.13 1.25 — — — P — < 0.05 < 0.05 < 0.05 >0.05 — — — 注:与VT= 6 mL/kg.IBW比较*P < 0.05 表 3 不同潮气量对病人肺应变相关指标的影响(x±s; mL/kg.IBW)
对于C≥0.6组病人,当VT由6 mL/kg.IBW逐渐增加至12 mL/kg.IBW时,肺应变≥0.27的病人比例由11.1%逐渐升至62.5%,而C < 0.6组病人则由60.0%逐渐升至88.9%。与C≥0.6组的病人相比,C < 0.6组的病人在6 mL/kg.IBW、8 mL/kg.IBW和10 mL/kg.IBWVT通气时,肺应变≥0.27的病人比例增加,差异有统计学意义(P < 0.05),在12 mL/kg.IBWVT通气时差异无统计学意义(P>0.05)。在C≥0.6组的病人中,6 mL/kg.IBW、8 mL/kg.IBWVT通气时肺应变 < 0.27,10 mL/kg.IBW、12 mL/kg.IBWVT通气时肺应变>0.27(见表 3)。与6 mL/kg.IBW VT相比,8 mL/kg.IBW、10 mL/kg.IBW VT的肺应变差异无统计学意义(P>0.05),而与12 mL/kg.IBW VT的肺应变差异有统计学意义(P < 0.05)。C < 0.6组的病人中,与6 mL/kg.IBW VT相比,8 mL/kg.IBW、10 mL/kg.IBW和12 mL/kg.IBW VT的肺应变差异无统计学意义(P>0.05),且均>0.27(见表 3)。
不同潮气量对急性呼吸窘迫综合征病人肺损伤的影响
Effect of different tidal volume on lung injury in patients with acute respiratory distress syndrome
-
摘要:
目的探讨不同潮气量对急性呼吸窘迫综合征(ARDS)病人肺损伤的影响。 方法以呼吸系统顺应性(C)=0.6 mL·cmH2O-1·kg-1为界将ARDS病人分为2组,其中C≥0.6 mL·cmH2O-1·kg-1者9例,C < 0.6 mL·cmH2O-1·kg-1者10例,分别记为C≥0.6组和C < 0.6组。测定不同潮气量6 mL/kg.IBW、8 mL/kg.IBW、10 mL/kg.IBW、12 mL/kg.IBW)下的呼气末肺容积(EELV),计算肺应变,观察不同潮气量下气道峰压(Ppeak)、气道平台压(Pplat)等的变化。 结果纳入行机械通气的ARDS病人19例,C≥0.6组9例,C < 0.6组10例。随着潮气量的增加,Ppeak和Pplat均逐渐增加,且Pplat均≤30cmH2O。与6 mL/kg.IBW潮气量相比,8 mL/kg.IBW、10 mL/kg.IBW和12 mL/kg.IBW潮气量的Pplat差异均有统计学意义(P < 0.05)。在所有病人中,潮气量由6 mL/kg.IBW逐渐增加至12 mL/kg.IBW时,肺应变由(0.31±0.27)逐渐增加至(0.52±0.46),且潮气量和肺应变呈显著正相关关系(r=0.978,P < 0.01)。对于C≥0.6组的病人,与6 mL/kg.IBW潮气量相比,仅12 mL/kg.IBW潮气量的肺应变明显增加,差异有统计学意义(P < 0.05),且10 mL/kg.IBW、12 mL/kg.IBW潮气量通气时肺应变>0.27。C < 0.6组的病人中,与6 mL/kg.IBW潮气量相比,8 mL/kg.IBW、10 mL/kg.IBW和12 mL/kg.IBW潮气量的肺应变差异无统计学意义(P>0.05),且不同潮气量时肺应变均>0.27。 结论C≥0.6 mL·cmH2O-1·kg-1的ARDS病人,在机械通气时潮气量适当增加至8 mL/kg.IBW并不明显加重肺损伤;而C < 0.6 mL·cmH2O-1·kg-1的病人即使采用6 mL/kg.IBW潮气量通气仍可致严重肺损伤。 Abstract:ObjectiveTo investigate the effects of different tidal volume on lung injury in patients with acute respiratory distress syndrome(ARDS). MethodsThe respiratory system compliance(C)=0.6 mL·cmH2O-1·kg-1 was set as the critic point, the patients were divided into the C≥0.6 group[9 cases with (C)≥0.6 mL·cmH2O-1·kg-1 and C < 0.6 group(10 cases with C < 0.6 mL·cmH2O-1·kg-1).At different tidal volume (6 mL/kg.IBW, 8 mL/kg.IBW, 10 mL/kg.IBW, 12 mL/kg.IBW), the end-expiratory lung volume(EELV) was detected, the pulmonary strain was calculated, and the changes of peak pressure(Ppeak) and plateau pressure(Pplat) were observed. ResultsWith the increasing of tidal volume, the Ppeak and Pplat increased, and the Pplat was ≤30 cmH2O.The differences of the Pplat between the tidal volume of 6 mL/kg.IBW and 8 mL/kg.IBW, 10 mL/kg.IBW, 12 mL/kg.IBW were statistically significant(P < 0.05).When the tidal volume increased gradually from 6 mL/kg.IBW to 12 mL/kg.IBW, the the pulmonary strain increased from (0.31±0.27) to (0.52±0.46), and the tidal volume was positively correlated with pulmonary strain(r=0.978, P < 0.01).Compared with 6 mL/kg.IBW, the pulmonary strain in C≥0.6 group significantly increased under 12 mL/kg.IBW tidal volume ventilation, and the difference of which was statistically significant(P < 0.05).Under 10 mL/kg.IBW and 12 mL/kg.IBW tidal volume ventilation, the pulmonary strain was more than 0.27.Compared with VT=6 mL/kg.IBW, the differences of the pulmonary strain in C < 0.6 group among 8 mL/kg·IBW, 10 mL/kg·IBW and 12 mL/kg.IBW tidal volume ventilation were not statistically significant(P>0.05), and the pulmonary strain under different tidal volumes was more than 0.27. ConclusionsFor the ARDS patients with C≥0.6mL·cmH2O-1·kg-1, the tidal volume increasing to 8 mL/kg.IBW does not aggravate lung injury.For the ARDS patients with C < 0.6mL·cmH2O-1·kg-1, the ventilation with 6 mL/kg.IBW tidal volume can still aggravate lung injury. -
表 1 病人的一般情况比较(x±s)
分组 n 男性 年龄/岁 IBW/kg APACHE Ⅱ/分 Murray评分/分 (PaO2/FiO2)/mmHg VT/(mL/kg.IBW) PEEP/cmH2O FRC/mL EELV/mL C/mL·cmH2O-1·kg-1 肺应变 C≥0.6 9 7 71±12 65.4±7.9 18.6±8.3 2.2±0.4 212±69 6.7±1.1 8.3±1.6 1 905±732 2 546±1 024 0.83±0.20 0.19±0.08 C < 0.6 10 6 68±17 64.4±7.0 19.9±5.6 2.6±0.6 189±103 6.5±1.3 8.1±1.9 943±589 1 267±689 0.49±0.07 0.42±0.20 t — — 0.44 0.29 0.40 1.69 0.56 0.36 0.25 3.17 3.23 5.06 3.22 P — >0.05* >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 < 0.01 < 0.01 < 0.01 < 0.01 *示Fisher确切概率 表 2 不同VT对ARDS病人气道压力的影响(x±s; mL/kg·IBW)
分组 n 基础设置 6 8 10 12 F P MS组内 PEEP/cmH2O C≥0.6 9 8.3±1.6 8.3±1.6 8.3±1.6 8.3±1.6 8.1±1.6 0.03 >0.05 2.560 C < 0.6 10 8.1±1.9 8.1±1.9 8.1±2.0 8.1±2.0 8.1±2.0 0.00 >0.05 3.844 T — 0.25 0.25 0.24 0.24 0.24 — — — P — >0.05 >0.05 >0.05 >0.05 >0.05 — — — Ppeak/cmH2O C≥0.6 9 21.6±4.4 20.1±4.4 24.4±4.0 31.3±5.7* 34.9±4.9* 16.48 < 0.01 366.712 C < 0.6 10 27.1±4.1 27.1±3.9 31.0±4.9 33.9±4.9* 35.6±5.3* 6.93 < 0.01 149.901 t — 2.82 3.68 3.19 1.07 0.30 — — — P — < 0.05 < 0.01 < 0.01 >0.05 >0.05 — — — Pplat/cmH2O C≥0.6 9 16.9±3.0 15.7±2.5 19.3±2.5* 22.3±3.1* 24.4±2.3* 16.33 < 0.01 118.921 C < 0.6 10 21.4±2.9 21.8±2.6 25.6±4.1 26.7±3.2* 27.6±2.6* 8.29 < 0.01 81.221 t — 3.32 5.20 3.99 3.09 2.83 — — — P — < 0.01 < 0.01 < 0.01 < 0.01 < 0.05 — — — 注:与VT= 6 mL/kg.IBW比较*P < 0.05 表 3 不同潮气量对病人肺应变相关指标的影响(x±s; mL/kg.IBW)
分组 n 6 8 10 12 F P MS组内 C/mL·cmH2O-1·kg-1 C≥0.6 9 0.85±0.23 0.75±0.14 0.70±0.11 0.73±0.10 1.61 >0.05 0.038 C < 0.6 10 0.45±0.08 0.40±0.16 0.48±0.10 0.47±0.09 1.01 >0.05 0.013 t — 5.18 5.05 4.57 5.97 — — — P — < 0.01 < 0.01 0.01 < 0.01 — — — EELV/mL C≥0.6 9 2 804±1 562 2 717±1 124 2 628±1 086 2 534±1 048 0.08 >0.05 121268.000 C < 0.6 10 1 317±775 1 347±886 1 860±1 323 1 482±1 230 0.54 >0.05 622710.000 t — 2.67 2.97 1.37 1.20 — — — P — < 0.05 < 0.01 >0.05 >0.05 — — — 肺应变 C≥0.6 9 0.17±0.08 0.22±0.09 0.28±0.11 0.36±0.17* 4.34 < 0.05 0.060 C < 0.6 10 0.44±0.32 0.64±0.61 0.67±0.60 0.67±0.59 0.42 >0.05 0.123 t — 2.46 2.04 1.92 1.52 — — — P — < 0.05 >0.05 >0.05 >0.05 — — — 肺应变≥0.27 C≥0.6 9 11.1 22.2 44.4 62.5 — — — C < 0.6 10 60.0 77.8 88.9 88.9 — — — z — 2.21 2.52 2.13 1.25 — — — P — < 0.05 < 0.05 < 0.05 >0.05 — — — 注:与VT= 6 mL/kg.IBW比较*P < 0.05 -
[1] ARDS Definition Task Force, RANIERI VM, RUBENFELD GD, et al.Acute respiratory distress syndrome:the Berlin Definition[J].JAMA, 2012, 307(23):2526. [2] TREMBLAY LN, SLUTSKY AS.Ventilator-induced lung injury:from the bench to the bedside[J].Intensive Care Med, 2006, 32(1):24. [3] The Acute Respiratory Distress Syndrome Network.Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome[J].N Engl J Med, 2000, 342(18):1301. [4] DEANS KJ, MINNECI PC, CUI X, et al.Mechanical ventilation in ARDS:one size does not fit all[J].Crit Care Med, 2005, 33(5):1141. [5] TERRAGNI PP, ROSBOCH G, TEALDI A, et al.Tidal hyperinflation during low tidal volume ventilation in acute respiratory distress syndrome[J].Am J Respir Crit Care Med, 2007, 175(2):160. [6] DEANS KJ, MINNECI PC, SUFFREDINI AF, et al.Randomization in clinical trials of titrated therapies:unintended consequences of using fixed treatment protocols[J].Crit Care Med, 2007, 35(6):1509. [7] TERRAGNI PP, DEL SORBO L, MASCIA L, et al.Tidal volume lower than 6 mL/kg enhances lung protection:role of extracorporeal carbon dioxide removal[J].Anesthesiology, 2009, 111(4):826. [8] GATTINONI L.Counterpoint:is low tidal volume mechanical ventilation preferred for all patients on ventilation? No[J].Chest, 2011, 140(1):11. [9] CHIUMELLO D, CARLESSO E, CADRINGHER P, et al.Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome[J].Am J Respir Crit Care Med, 2008, 178(4):346. [10] GONZALEZ-LOPEZ A, GARCIA-PRIETO E, BATALLA-SOLIS E, et al.Lung strain and biological response in mechanically ventilated patients[J].Intensive Care Med, 2012, 38(2):240. [11] OLEGARD C, SONDERGAARD S, HOULTZ E, et al.Estimation of functional residual capacity at the bedside using standard monitoring equipment:a modified nitrogen washout/washin technique requiring a small change of the inspired oxygen fraction[J].Anesth Analg, 2005, 101(1):206. [12] CHIUMELLO D, CRESSONI M, CHIERICHETTI M, et al.Nitrogen washout/washin, helium dilution and computed tomography in the assessment of end expiratory lung volume[J].Crit Care, 2008, 12(6):R150. [13] ANDRIDGE RR, LITTLE RJ.A review of hot deck imputation for survey non-response[J].Int Stat Rev, 2010, 78(1):40. [14] GATTINONI L, CAIRONI P, CRESSONI M, et al.Lung recruitment in patients with the acute respiratory distress syndrome[J].N Engl J Med, 2006, 354(17):1775. [15] HAGER DN, KRISHNAN JA, HAYDEN DL, et al.Tidal volume reduction in patients with acute lung injury when plateau pressures are not high[J].Am J Respir Crit Care Med, 2005, 172(10):1241. [16] RYLANDER C, TYLÉN U, ROSSI-NORRLUND R, et al.Uneven distribution of ventilation in acute respiratory distress syndrome[J].Crit Care, 2005, 9(2):R165. [17] MACNAUGHTON PD, EVANS TW.Measurement of lung volume and DLCO in acute respiratory failure[J].Am J Respir Crit Care Med, 1994, 150(3):770. [18] PUYBASSET L, CLUZEL P, GUSMAN P, et al.Regional distribution of gas and tissue in acute respiratory distress syndrome[J].Intensive Care Med, 2000, 26(7):857. [19] MEAD J, TAKISHIMA T, LEITH D.Stress distribution in lungs, a model of pulmonary elasticity[J].J Appl Physiol, 1970, 28(5):596. [20] SUNDARESAN A, GEOFFREY CHASE J, HANN CE, et al.Dynamic functional residual capacity can be estimated using a stress-strain approach[J].Comput Methods Programs Biomed, 2011, 101(2):135. [21] GATTINONI L, PROTTI A, CAIRONI P, et al.Ventilator-induced lung injury:the anatomical and physiological framework[J].Crit Care Med, 2010, 38(10 Suppl):S539.