肺段肺复张对急性呼吸窘迫综合征患者预后的影响

doi:10.3877/cma.j.issn.1674-6902.2022.06.006

目的

分析肺段肺复张对急性呼吸窘迫综合征(acute respiratory distress syndrome, ARDS)患者预后的影响。

方法

选择2020年4月至2022年4月我院收治的重症ARDS患者30例，随机分为观察组17例，对照组13例，对照组采取肺保护性通气策略联合俯卧位通气，观察组在此基础上给予肺段肺复张。比较两组患者呼吸参数、动脉血气、血流动力学、并发症及预后。

结果

治疗72 h后，观察组呼吸末正压、平台压低于对照组，静态肺顺应性高于对照组(P<0.05)；观察组pH和氧合指数高于对照组，二氧化碳分压低于对照组(P<0.05)；观察组进行肺段肺复张前后平均动脉压、心率变化无统计学差异(P>0.05)；观察组每搏输出量指数高于对照组，血管外肺水指数和肺血管通透性指数低于对照组(P<0.05)；观察组与对照组气胸及纵膈气肿发生率差异无统计学意义(P>0.05)，住院期间病死率观察组较对照组下降(P<0.05)。

结论

肺段肺复张能改善重症ARDS患者呼吸功能，对血流动力学影响较小，不增加气胸及纵膈气肿等并发症，可改善患者预后。

关键词: 肺段肺复张, 急性呼吸窘迫综合征, 球囊导管

Objective

To evaluate the effects of bronchopulmonary segments recruitment on clinical outcomes in patients with severe acute respiratory distress syndrome.

Methods

From April 2020 to April 2022, 30 patients with severe ARDS in our hospital were randomly divided into an observation group 17 cases and a control group 13 cases. All patients were given lung protective ventilation strategies and prone position, and the observation group was additionally given bronchopulmonary segments recruitment. The respiratory parameters, arterial blood gas, hemodynamic, complications and outcomes were compared between the two groups.

Results

After 72 hours of treatment, static compliance of the respiratory system, pH, the oxygenation index, stroke volume index in the observation group were higher than those of the control group(P<0.05). whereas positive end-expiratory pressure, partial pressure of carbon dioxide, the plateau pressure, extravascular lung water index, pulmonary vascular permeability index and mortality during hospital were lower than those of control group(P<0.05). No significant difference between the two groups were shown in the mean arterial pressure, heart rate, complications.

Conclusions

In patients with severe ARDS, based on lung protective ventilation strategy and prone ventilation, application of bronchopulmonary segments recruitment can improve the respiratory function, has little effect on hemodynamics, does not increase the complications such as pneumothorax and mediastinum emphysema. Therefore, bronchopulmonary segments recruitment can significantly improve the clinical outcomes of severe ARDS patients.

Key words: Bronchopulmonary segments recruitment, Acute respiratory distress syndrome, Balloon catheter

图1 自制肺复张充气测压套件

图2 纤支镜引导下进行球囊导管定位及封闭支气管，进行肺段肺复张；注：A：检查球囊膨胀，B：复张前纤支镜引导球囊导管至目标肺段支气管开口，C：纤支镜下球囊充气，封闭支气管开口

表1 两组患者呼吸参数比较

组　别	例数	PEEP(cmH₂O)		Pplat(cmH₂O)		C_Lst(ml/cmH₂O)
组　别	例数	入组时	72 h	入组时	72 h	入组时	72 h
观察组	17	16.11±4.23	8.23±2.14^a	29.56±7.32	20.32±5.15^a	29.33±15.49	38.87±13.31^a
对照组	13	16.32±3.13	10.37±3.22^a	29.57±6.34	23.68±6.38^a	30.18±14.62	34.75±14.34^a
P值		0.343	0.025	0.862	0.033	0.432	0.004

表1 两组患者呼吸参数比较

组　别	例数	PEEP(cmH₂O)		Pplat(cmH₂O)		C_Lst(ml/cmH₂O)
组　别	例数	入组时	72 h	入组时	72 h	入组时	72 h
观察组	17	16.11±4.23	8.23±2.14^a	29.56±7.32	20.32±5.15^a	29.33±15.49	38.87±13.31^a
对照组	13	16.32±3.13	10.37±3.22^a	29.57±6.34	23.68±6.38^a	30.18±14.62	34.75±14.34^a
P值		0.343	0.025	0.862	0.033	0.432	0.004

表2 两组患者血气分析结果比较

组　别	例数	pH		PaO₂/FiO₂(mmHg)		PaCO₂(mmHg)
组　别	例数	入组时	72 h	入组时	72 h	入组时	72 h
观察组	17	7.23±0.02	7.44±0.04^a	72.24±16.32	181.47±31.29^a	55.41±5.35	43.56±4.67^a
对照组	13	7.26±0.02	7.35±0.03^a	73.17±14.34	137.78±35.29^a	54.89±6.48	47.73±4.29^a
P值		0.577	0.026	0.575	0.000	0.138	0.000

表2 两组患者血气分析结果比较

组　别	例数	pH		PaO₂/FiO₂(mmHg)		PaCO₂(mmHg)
组　别	例数	入组时	72 h	入组时	72 h	入组时	72 h
观察组	17	7.23±0.02	7.44±0.04^a	72.24±16.32	181.47±31.29^a	55.41±5.35	43.56±4.67^a
对照组	13	7.26±0.02	7.35±0.03^a	73.17±14.34	137.78±35.29^a	54.89±6.48	47.73±4.29^a
P值		0.577	0.026	0.575	0.000	0.138	0.000

表3 两组PiCCO监测指标结果比较

组　别	例数	SVI(ml/m²)		ELWI(ml/kg)		PVPI
组　别	例数	入组时	72 h	入组时	72 h	入组时	72 h
观察组	17	31.17±4.07	45.67±5.39^a	14.67±3.35	7.37±2.14^a	6.27±1.05	4.15±1.21^a
对照组	13	30.45±5.34	40.37±4.13^a	13.45±3.14	10.56±3.27^a	6.17±1.13	4.74±1.15^a
P值		0.324	0.035	0.248	0.000	0.618	0.003

表3 两组PiCCO监测指标结果比较

组　别	例数	SVI(ml/m²)		ELWI(ml/kg)		PVPI
组　别	例数	入组时	72 h	入组时	72 h	入组时	72 h
观察组	17	31.17±4.07	45.67±5.39^a	14.67±3.35	7.37±2.14^a	6.27±1.05	4.15±1.21^a
对照组	13	30.45±5.34	40.37±4.13^a	13.45±3.14	10.56±3.27^a	6.17±1.13	4.74±1.15^a
P值		0.324	0.035	0.248	0.000	0.618	0.003

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Effect of bronchopulmonary segments recruitment on the survival of patients with severe acute respiratory distress syndrome

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Effect of bronchopulmonary segments recruitment on the survival of patients with severe acute respiratory distress syndrome