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中华肺部疾病杂志(电子版)

中华肺部疾病杂志(电子版) ›› 2025, Vol. 18 ›› Issue (06) : 866 -871. doi: 10.3877/cma.j.issn.1674-6902.2025.06.003

论著

跨肺驱动压导向呼气末正压通气对急性呼吸窘迫综合征患者肺功能及预后的影响
吴蓉1, 蔡喆燚1, 黄运华1, 乐金海1, 张萍2, 陈献1, 易琼1,†()   
  1. 1410000　长沙，湖南中医药大学第一附属医院重症医学科
    2410000　长沙，湖南中医药大学第一附属医院手外创伤科
  • 收稿日期:2025-07-22 出版日期:2025-12-25
  • 通信作者: 易琼
  • 基金资助:
    国家自然科学基金资助项目（青年科学基金项目）(82204986); 湖南省卫健委科研项目(202103031584); 国家中医优势专科-重症医学科(czxm-zzyxk-2024001); 湖南中医药大学校院联合基金重点项目(2025XYLH010)

Effect of transpulmonary driving pressure guided positive end-expiratory pressure ventilation on pulmonary function and prognosis in patients with acute respiratory distress syndrome

Rong Wu1, Zheyi Cai1, Yunhua Huang1, Jinhai Le1, Ping Zhang2, Xian Chen1, Qiong Yi1,†()   

  1. 1Department of Critical Care Medicine, The First Hospital of Hunan University of Chinese Medicine, Changsha 410000, China
    2Department of External Hand Trauma, The First Hospital of Hunan University of Chinese Medicine, Changsha 410000, China
  • Received:2025-07-22 Published:2025-12-25
  • Corresponding author: Qiong Yi
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引用本文：

吴蓉, 蔡喆燚, 黄运华, 乐金海, 张萍, 陈献, 易琼. 跨肺驱动压导向呼气末正压通气对急性呼吸窘迫综合征患者肺功能及预后的影响[J/OL]. 中华肺部疾病杂志(电子版), 2025, 18(06): 866-871.

Rong Wu, Zheyi Cai, Yunhua Huang, Jinhai Le, Ping Zhang, Xian Chen, Qiong Yi. Effect of transpulmonary driving pressure guided positive end-expiratory pressure ventilation on pulmonary function and prognosis in patients with acute respiratory distress syndrome[J/OL]. Chinese Journal of Lung Diseases(Electronic Edition), 2025, 18(06): 866-871.

目的

探讨跨肺驱动压导向呼气末正压(positive end-expiratory pressure, PEEP)通气对急性呼吸窘迫综合征(acute respiratory distress syndrome, ARDS)患者肺功能及预后的影响。

方法

选择2021年5月至2024年7月我院收治的51例ARDS患者为对象，随机分为对照组25例和观察组26例。对照组接受潮气量PEEP滴定，观察组接受跨肺驱动压导向PEEP滴定。检测患者肺功能参数和血流动力学参数，记录住院时间、ICU住院时间、机械通气持续时间、脱机成功率、肺不张发生率及住院期间病死率。

结果

观察组PEEP(8.36±1.72)cmH2O高于对照组(6.17±1.58)cmH2O(t＝4.730，P<0.05)；生理无效腔分数(Vd/Vt)(31.97±8.22)%低于对照组(37.24±10.26)%(t＝2.028，P<0.05)。两组入住ICU前呼吸力学和血气分析差异无统计学意义(P>0.05)；机械通气48 h后观察组静态顺应性(45.76±20.00)ml/cmH2O、动脉血氧分压(arterial partial pressure of oxygen, PaO2)(127.73±32.27)mmHg、氧合指数(PaO2/FiO2)(380.40±106.53)、高于对照组静态顺应性(36.40±11.97)ml/cmH2O、PaO2(106.96±30.76)mmHg、PaO2/FiO2(310.17±97.29)(r＝2.048，2.351，2.455，P<0.05)；动态顺应性(29.27±8.17)ml/cmH2O、气道阻力(9.20±5.67)ml/cmH2O·L－1·s－1、血氧饱和度(blood oxygen saturation, SaO2)(105.29±19.64)%优于对照组动态顺应性(25.88±5.73)ml/cmH2O、气道阻力(11.25±7.65)ml/cmH2O·L－1·s－1、SaO2(103.08±17.25)%(t＝1.709，1.090，0.427，P>0.05)。两组血流动力学参数差异无统计学意义(P>0.05)。观察组机械通气8.00(6.00，13.00)d、住院时间15.00(9.50，26.50)d和肺不张2例(7.69%)少于对照组机械通气20.00(9.00，28.00)d、住院时间33.00(12.50，62.00)d和肺不张5例(20.00%)；观察组脱机成功14例(53.85%)高于对照组5例(20.00%)(P<0.05)。住院期间，观察组生存者20例(76.92%)，死亡者6例(23.08%)；对照组生存者12例(48.00%)，死亡者13例(52.00%)。观察组中位生存时间30 d长于对照组23 d(P<0.05)。

结论

跨肺驱动压导向PEEP可改善ARDS患者氧合和肺顺应性，减少机械通气时长，降低肺不张和院内死亡风险，有助于提高脱机成功率。

关键词: 急性呼吸窘迫综合征, 跨肺驱动压, 呼气末正压通气, 肺功能, 预后
Objective

To investigate the effect of transpulmonary driving pressure-guided positive end-expiratory pressure (PEEP) ventilation on lung function and prognosis in patients with acute respiratory distress syndrome (ARDS).

Methods

Fifty-one ARDS patients admitted to our hospital from May 2021 to July 2024 were selected and randomly divided into a control group (n=25) and an observation group (n=26). The control group received tidal volume PEEP titration, while the observation group received transpulmonary driving pressure-guided PEEP titration. Lung function parameters and hemodynamic parameters were measured, and hospital stay, ICU stay, duration of mechanical ventilation, weaning success rate, incidence of atelectasis, and in-hospital mortality were recorded.

Results

The PEEP in the observation group was (8.36±1.72) cmH2O, higher than that in the control group (6.17±1.58) cmH2O(t=4.730, P<0.05). The physiological dead space fraction (Vd/Vt) in the observation group was (31.97±8.22)%, lower than that in the control group (37.24±10.26)%(t=2.028, P<0.05). There were no statistically significant differences in respiratory mechanics and blood gas analysis between the two groups before ICU admission (P>0.05). After 48 hours of mechanical ventilation, the observation group showed higher static compliance (45.76±20.00) ml/cmH2O, arterial partial pressure of oxygen (PaO2) (127.73±32.27) mmHg, and oxygenation index (PaO2/FiO2) (380.40±106.53) compared to the control group′s static compliance (36.40±11.97) ml/cmH2O, PaO2(106.96±30.76)mmHg, and PaO2/FiO2(310.17 ± 97.29) (r=2.048, 2.351, 2.455, P<0.05). Additionally, the observation group′s dynamic compliance (29.27±8.17) ml/cmH2O, airway resistance (9.20±5.67) cmH2O·L-1·s-1, and blood oxygen saturation (SaO2) (105.29±19.64)% were better than the control group′s dynamic compliance (25.88±5.73) ml/cmH2O, airway resistance (11.25±7.65) cmH2O·L-1·s-1, and SaO2 (103.08±17.25)% (t=1.709, 1.090, 0.427, P>0.05). There were no statistically significant differences in hemodynamic parameters between the two groups (P>0.05). The duration of mechanical ventilation [8.00(6.00, 13.00)days], hospital stay [15.00 (9.50, 26.50) days], and incidence of atelectasis [2 cases (7.69%)] in the observation group were lower than those in the control group [20.00 (9.00, 28.00) days, 33.00 (12.50, 62.00) days, and 5 cases (20.00%), respectively]. The weaning success rate in the observation group [14 cases (53.85%)] was higher than that in the control group [5 cases(20.00%)] (P<0.05). During hospitalization, there were 20 survivors (76.92%) and 6 deaths (23.08%) in the observation group, compared to 12 survivors (48.00%) and 13 deaths (52.00%) in the control group. The median survival time in the observation group was 30 days, longer than that in the control group (23 days) (P<0.05).

Conclusion

Transpulmonary driving pressure-guided PEEP can improve oxygenation and lung compliance in ARDS patients, reduce the duration of mechanical ventilation, lower the risk of atelectasis and in-hospital mortality, and help improve the weaning success rate.

Key words: Acute respiratory distress syndrome, Transpulmonary driving pressure, positive end-expiratory pressure ventilation, Pulmonary function, Prognosis
表1 两组ARDS患者临床资料结果比较
临床资料 观察组(n＝26) 对照组(n＝25) t/χ2/Z值 P值
体质量指数[kg/m2，(±s)] 25.89±5.36 27.50±6.96 0.928 0.358
查尔森合并症指数[分，M(Q25，Q75)] 3.00(1.00，4.00) 3.00(2.00，4.00) －0.931 0.352
SOFA评分[分，M(Q25，Q75)] 4.00(4.00，5.00) 4.00(3.00，4.00) －0.960 0.337
实验室指标[M(Q25，Q75)]        
WBC(/mm3) 7 800.00(7 080.00，11 625.00) 8 940.00(7 670.00，12 000.00) －0.989 0.323
LYM(/mm3) 9.00(6.00，13.45) 8.00(5.95，11.00) －0.936 0.349
CRP(mg/dl) 12.53(2.75，17.23) 13.00(5.92，17.15) －0.716 0.474
PCT(ng/ml) 0.11(0.05，0.19) 0.14(0.06，0.29) －0.340 0.734
入ICU前住院时间[d，(±s)] 33.42±10.75 32.56±9.89 0.297 0.768
图1 ARDS患者典型CT图像。肺部片状高密度影，见空气支气管征，双肺多发结节，胸膜凹陷征象；双肺胸膜下散在索条、斑片灶；左侧胸腔少量积液、胸膜增厚，双侧胸腔少许积液
表2 两组ARDS患者呼吸力学及血气分析结果(±s)
呼吸力学/血气分析参数 观察组(n＝26) 对照组(n＝25) t值 P值
静态顺应性(ml/cmH2O)        
基线 34.56±10.70 35.53±13.29 0.288 0.775
机械通气48 h 45.76±20.00a 36.40±11.97 2.048 0.046
动态顺应性(ml/cmH2O)        
基线 25.52±6.88 25.53±5.23 0.006 0.995
机械通气48 h 29.27±8.17 25.88±5.73 1.709 0.094
气道阻力(ml/cmH2O·L－1·s－1)        
基线 9.32±5.91 11.44±8.79 1.014 0.315
机械通气48 h 9.20±5.67 11.25±7.65 1.090 0.281
pH        
基线 7.31±0.09 7.35±0.09 1.587 0.119
机械通气48 h 7.35±0.38 7.45±0.33 1.002 0.321
PaO2(mmHg)        
基线 108.19±30.98 103.44±33.57 0.551 0.584
机械通气48 h 127.73±32.27 106.96±30.76 2.351 0.023
PaCO2(mmHg)        
基线 48.96±12.75 45.56±11.36 1.146 0.257
机械通气48 h 46.35±11.41 42.84±9.56 1.188 0.240
PaO2/FiO2        
基线 298.08±126.81 308.72±118.12 0.310 0.758
机械通气48 h 380.40±106.53a 310.17±97.29 2.455 0.018
SaO2(%)        
基线 91.37±17.28 89.65±16.84 0.360 0.720
机械通气48 h 105.29±19.64a 103.08±17.25a 0.427 0.671
表3 两组ARDS患者血流动力学结果比较(±s)
血流动力学特　征 观察组(n＝26) 对照组(n＝25) t值 P值
心率(次/min)        
基线 100.93±20.57 104.35±23.12 0.559 0.579
机械通气48 h 97.26±20.17 102.03±18.29 0.884 0.381
平均动脉压(mmHg)        
基线 79.57±13.05 81.44±16.28 0.451 0.654
机械通气48 h 80.14±12.79 82.36±15.01 0.569 0.572
中心静脉压(mmHg)        
基线 10.19±2.91 10.01±3.04 0.216 0.830
机械通气48 h 11.27±2.93 10.36±2.88 1.118 0.269
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