Acute respiratory distress syndrome(ARDS) represents a serious problem in critically ill patients and is associated with in-hospital mortality rates of 33%-52%. Recruitment maneuvers(RMs) are a simple, low-cost, feasi...Acute respiratory distress syndrome(ARDS) represents a serious problem in critically ill patients and is associated with in-hospital mortality rates of 33%-52%. Recruitment maneuvers(RMs) are a simple, low-cost, feasible intervention that can be performed at the bedside in patients with ARDS. RMs are characterized by the application of airway pressure to increase transpulmonary pressure transiently. Once non-aerated lung units are reopened, improvements are observed in respiratory system mechanics, alveolar reaeration on computed tomography, and improvements in gas exchange(functional recruitment). However, the reopening process could lead to vascular compression, which can be associated with overinflation, and gas exchange may not improve as expected(anatomical recruitment). The purpose of this review was to discuss the effects of different RM strategies- sustained inflation, intermittent sighs, and stepwise increases of positive end-expiratory pressure(PEEP) and/or airway inspiratory pressure- on the following parameters: hemodynamics, oxygenation, barotrauma episodes, and lung recruitability through physiological variables and imaging techniques. RMs and PEEP titration are interdependent events for the success of ventilatory management. PEEP should be adjusted on the basis of respiratory system mechanics and oxygenation. Recent systematic reviews and meta-analyses suggest that RMs are associated with lower mortality in patients with ARDS. However, the optimal RM method(i.e., that providing the best balance of benefit and harm) and the effects of RMs on clinical outcome are still under discussion, and further evidence is needed.展开更多
目的研究跨肺压导向急性呼吸窘迫综合征(ARDS)患者最佳呼气末正压(PEEP)选择的临床意义。方法选择需要进行机械通气的跨肺压导向ARDS患者68例,随机分为对照组和观察组,每组34例。观察组患者在进行充分肺腹张后,调整PEEP至30 cm H2O(1 cm...目的研究跨肺压导向急性呼吸窘迫综合征(ARDS)患者最佳呼气末正压(PEEP)选择的临床意义。方法选择需要进行机械通气的跨肺压导向ARDS患者68例,随机分为对照组和观察组,每组34例。观察组患者在进行充分肺腹张后,调整PEEP至30 cm H2O(1 cm H2O=0.098 k Pa),每隔5分钟降低3 cm H2O,直至降为0,在PEEP递减过程中分别采用跨肺压法、最小死控分数法、最大顺应性法,最佳氧合法选择最佳的PEEP对呼吸力学及气体交换。对照组采用常规治疗方式。分别监测2组患者在治疗前后48、72 h的氧合指数,经皮脉氧饱和度、肺顺应性、平均动脉压(MAP)、治疗后4周病死率的情况。结果 2组患者治疗前氧合指数和Sp O2差异无统计学意义(P>0.05)。治疗后48、72 h氧合指数比较均比治疗前高,且观察组优于对照组,差异均有统计学意义(P<0.05)。治疗前观察组的肺顺应性和MAP指数和对照组比较,差异无统计学意义(P>0.05)。治疗后48 h观察组肺顺应性明显优于对照组(P<0.01)。跨肺压法、最小死控分数法、最大顺应性法,最佳氧合法的PEEP数值对比均高于基础状态,最佳氧合法的数值较其他三种方法显著升高(P<0.05)。跨肺压法、最小死控分数法、最大顺应性法之间比较差异无统计学意义(P>0.05)。结论 ARDS机械通气患者采用跨肺压法选择最佳PEEP,在保证能促进塌陷肺泡腹张情况下,还可以有效改善氧合和肺顺应性,同时还能避免导致肺泡过度膨胀。展开更多
Background Intra-abdominal hypertension （IAH） is common in acute respiratory distress syndrome （ARDS） patients and when resulting in decrease of chest wall compliance will weaken the effect of positive end expirat...Background Intra-abdominal hypertension （IAH） is common in acute respiratory distress syndrome （ARDS） patients and when resulting in decrease of chest wall compliance will weaken the effect of positive end expiratory pressure （PEEP）. We investigated the effect of PEEP titrated by transpulmonary pressure （Ptp） on oxygenation and respiratory mechanics in ARDS patients with IAH compared with PEEP titrated by ARDSnet protocol. Methods ARDS patients admitted to the intensive care unit （ICU） of the Zhongda Hospital were enrolled. Patients were ventilated with volume control mode with tidal volume of 6 ml/kg under two different PEEP levels titrated by Ptp method and ARDSnet protocol. Respiratory mechanics, gas exchange and haemodynamics were measured after 30 minutes of ventilation in each round. IAH was defined as intra-abdominal pressure of 12 mmHg or more, Results Seven ARDS patients with IAH and 8 ARDS patients without IAH were enrolled. PEEP titrated by Ptp were significant higher than PEEP titrated by ARDSnet protocol in both ARDS patients with IAH （（17.3±2.6）cmH20 vs. （6.3±1.6） cmH2O and without IAH （（9.5±2.1） cmH2O vs. （7.8±1.9） cmH2O）. Arterial pressure of O2/fraction of inspired oxygen （PaO2/ FiO2） was much higher under PEEP titrated by Ptp when compared with PEEP titrated by ARDSnet protocol in ARDS patients with IAH （（27.2±4.0） cmHg vs. （20.9± 5.0） cmHg. But no significant difference of PaO2/FiO2 between the two methods was found in ARDS patients without IAH. In ARDS patients with IAH, static compliance of lung and respiratory system were higher under PEEP titrated by Ptp than by ARDSnet protocol. In ARDS patients with IAH, central venous pressure （CVP） was higher during PEEP titrated by Ptp than by ARDSnet protocol. Conclusion Positive end expiratory pressure titrated by transpulmonary pressure was higher than PEEP titrated by ARDSnet protocol and improved oxygenation and respiratory mechanics in ARDS patients with IAH.展开更多
目的探讨不同腹腔内压力(IAP)对急性肺损伤(ALI)家猪呼吸力学及血流动力学的影响。方法将8只家猪经耳缘持续静脉泵入油酸0.1 mL/kg制作急性肺损伤模型,采用氮气气腹法制作不同腹腔压力模型,随机将IAP设置为0、15和25 mm Hg,即分为IAP0组...目的探讨不同腹腔内压力(IAP)对急性肺损伤(ALI)家猪呼吸力学及血流动力学的影响。方法将8只家猪经耳缘持续静脉泵入油酸0.1 mL/kg制作急性肺损伤模型,采用氮气气腹法制作不同腹腔压力模型,随机将IAP设置为0、15和25 mm Hg,即分为IAP0组、IAP15组和IAP25组,动态监测心率(HR)、平均动脉压(MAP)、中心静脉压(CVP),采用脉搏轮廓持续心排出量监测(PiCCO)法动态监测心排出量(CO)、胸腔内血容量指数(ITBVI)等血流动力学指标,同时置入食管内压管动态监测食管内压(Pes)的变化。结果 IAP15组、IAP25组与IAP0组比较,Pes和气道峰压(Ppeak)均显著增加(P<0.01),肺顺应性(Cstat)则显著下降(P<0.05),跨肺压(Ptp)呈下降趋势,PaO2亦呈下降趋势,PaCO2则呈上升趋势,但均无统计学意义(P>0.05)。IAP15组、IAP25组与IAP0组比较,HR和CVP显著增加(P<0.05),CI和ITBVI则显著下降(P<0.05),但MAP无明显改变(P>0.05);ΔPes与CI的变化(ΔCI)呈负相关(r=-0.648,P<0.05)。结论急性肺损伤时,腹腔内压增高引起胸腔内压力增高,导致肺顺应性下降和心排出量下降。展开更多
目的:评价通过跨肺压导向滴定呼气末正压(PEEP)个体化治疗急性呼吸窘迫综合征(ARDS)与其他调整PEEP的方法相比对患者是否获益更多。方法:计算机检索PubMed、Embase、Web of Science、Cochrane Library、中国知网、中国生物医学文献、维...目的:评价通过跨肺压导向滴定呼气末正压(PEEP)个体化治疗急性呼吸窘迫综合征(ARDS)与其他调整PEEP的方法相比对患者是否获益更多。方法:计算机检索PubMed、Embase、Web of Science、Cochrane Library、中国知网、中国生物医学文献、维普、万方数据库中关于跨肺压导向PEEP滴定、其他方法调整PEEP治疗ARDS患者的相关随机对照研究,检索时间限定为建库以来至2021年8月15日,并对纳入文献进行meta分析。结果:共纳入16篇文献,累计样本量1075例,其中跨肺压导向PEEP滴定共540例,其他PEEP滴定方法共535例。meta分析结果显示:与其他方法调整PEEP相比,跨肺压导向PEEP滴定可改善ARDS患者的氧合指数(WMD=46.54,95%CI:27.63~65.46,P<0.05)、血氧饱和度(WMD=6.03,95%CI:4.67~7.39,P<0.05)、肺顺应性(WMD=6.97,95%CI:4.71~9.23,P<0.05)、28 d病死率(OR=0.55,95%CI:0.38~0.79,P=0.001)。结论:跨肺压导向PEEP滴定与其他滴定方法相比疗效、安全性更优。展开更多
基金Supported by Brazilian Council for Scientific and Technological Development(CNPq),Carlos Chagas Filho Rio de Janeiro State Research Foundation(FAPERJ),Department of Science and Technology(DECIT)/Brazilian Ministry of HealthCoordination for the Improvement of Higher Level Personnel(CAPES)
文摘Acute respiratory distress syndrome(ARDS) represents a serious problem in critically ill patients and is associated with in-hospital mortality rates of 33%-52%. Recruitment maneuvers(RMs) are a simple, low-cost, feasible intervention that can be performed at the bedside in patients with ARDS. RMs are characterized by the application of airway pressure to increase transpulmonary pressure transiently. Once non-aerated lung units are reopened, improvements are observed in respiratory system mechanics, alveolar reaeration on computed tomography, and improvements in gas exchange(functional recruitment). However, the reopening process could lead to vascular compression, which can be associated with overinflation, and gas exchange may not improve as expected(anatomical recruitment). The purpose of this review was to discuss the effects of different RM strategies- sustained inflation, intermittent sighs, and stepwise increases of positive end-expiratory pressure(PEEP) and/or airway inspiratory pressure- on the following parameters: hemodynamics, oxygenation, barotrauma episodes, and lung recruitability through physiological variables and imaging techniques. RMs and PEEP titration are interdependent events for the success of ventilatory management. PEEP should be adjusted on the basis of respiratory system mechanics and oxygenation. Recent systematic reviews and meta-analyses suggest that RMs are associated with lower mortality in patients with ARDS. However, the optimal RM method(i.e., that providing the best balance of benefit and harm) and the effects of RMs on clinical outcome are still under discussion, and further evidence is needed.
文摘目的研究跨肺压导向急性呼吸窘迫综合征(ARDS)患者最佳呼气末正压(PEEP)选择的临床意义。方法选择需要进行机械通气的跨肺压导向ARDS患者68例,随机分为对照组和观察组,每组34例。观察组患者在进行充分肺腹张后,调整PEEP至30 cm H2O(1 cm H2O=0.098 k Pa),每隔5分钟降低3 cm H2O,直至降为0,在PEEP递减过程中分别采用跨肺压法、最小死控分数法、最大顺应性法,最佳氧合法选择最佳的PEEP对呼吸力学及气体交换。对照组采用常规治疗方式。分别监测2组患者在治疗前后48、72 h的氧合指数,经皮脉氧饱和度、肺顺应性、平均动脉压(MAP)、治疗后4周病死率的情况。结果 2组患者治疗前氧合指数和Sp O2差异无统计学意义(P>0.05)。治疗后48、72 h氧合指数比较均比治疗前高,且观察组优于对照组,差异均有统计学意义(P<0.05)。治疗前观察组的肺顺应性和MAP指数和对照组比较,差异无统计学意义(P>0.05)。治疗后48 h观察组肺顺应性明显优于对照组(P<0.01)。跨肺压法、最小死控分数法、最大顺应性法,最佳氧合法的PEEP数值对比均高于基础状态,最佳氧合法的数值较其他三种方法显著升高(P<0.05)。跨肺压法、最小死控分数法、最大顺应性法之间比较差异无统计学意义(P>0.05)。结论 ARDS机械通气患者采用跨肺压法选择最佳PEEP,在保证能促进塌陷肺泡腹张情况下,还可以有效改善氧合和肺顺应性,同时还能避免导致肺泡过度膨胀。
基金This study was supported by the grants from Foundation of National Key Clinical Department of Critical Care Medicine （2010）, the Ministry of Health of China （Special Fund for Health scientific Research in the Public Interest Program No. 201202011） and the National Natural Science Foundation of China （No. 81070049 and No. 81170057）.
文摘Background Intra-abdominal hypertension （IAH） is common in acute respiratory distress syndrome （ARDS） patients and when resulting in decrease of chest wall compliance will weaken the effect of positive end expiratory pressure （PEEP）. We investigated the effect of PEEP titrated by transpulmonary pressure （Ptp） on oxygenation and respiratory mechanics in ARDS patients with IAH compared with PEEP titrated by ARDSnet protocol. Methods ARDS patients admitted to the intensive care unit （ICU） of the Zhongda Hospital were enrolled. Patients were ventilated with volume control mode with tidal volume of 6 ml/kg under two different PEEP levels titrated by Ptp method and ARDSnet protocol. Respiratory mechanics, gas exchange and haemodynamics were measured after 30 minutes of ventilation in each round. IAH was defined as intra-abdominal pressure of 12 mmHg or more, Results Seven ARDS patients with IAH and 8 ARDS patients without IAH were enrolled. PEEP titrated by Ptp were significant higher than PEEP titrated by ARDSnet protocol in both ARDS patients with IAH （（17.3±2.6）cmH20 vs. （6.3±1.6） cmH2O and without IAH （（9.5±2.1） cmH2O vs. （7.8±1.9） cmH2O）. Arterial pressure of O2/fraction of inspired oxygen （PaO2/ FiO2） was much higher under PEEP titrated by Ptp when compared with PEEP titrated by ARDSnet protocol in ARDS patients with IAH （（27.2±4.0） cmHg vs. （20.9± 5.0） cmHg. But no significant difference of PaO2/FiO2 between the two methods was found in ARDS patients without IAH. In ARDS patients with IAH, static compliance of lung and respiratory system were higher under PEEP titrated by Ptp than by ARDSnet protocol. In ARDS patients with IAH, central venous pressure （CVP） was higher during PEEP titrated by Ptp than by ARDSnet protocol. Conclusion Positive end expiratory pressure titrated by transpulmonary pressure was higher than PEEP titrated by ARDSnet protocol and improved oxygenation and respiratory mechanics in ARDS patients with IAH.
文摘目的探讨不同腹腔内压力(IAP)对急性肺损伤(ALI)家猪呼吸力学及血流动力学的影响。方法将8只家猪经耳缘持续静脉泵入油酸0.1 mL/kg制作急性肺损伤模型,采用氮气气腹法制作不同腹腔压力模型,随机将IAP设置为0、15和25 mm Hg,即分为IAP0组、IAP15组和IAP25组,动态监测心率(HR)、平均动脉压(MAP)、中心静脉压(CVP),采用脉搏轮廓持续心排出量监测(PiCCO)法动态监测心排出量(CO)、胸腔内血容量指数(ITBVI)等血流动力学指标,同时置入食管内压管动态监测食管内压(Pes)的变化。结果 IAP15组、IAP25组与IAP0组比较,Pes和气道峰压(Ppeak)均显著增加(P<0.01),肺顺应性(Cstat)则显著下降(P<0.05),跨肺压(Ptp)呈下降趋势,PaO2亦呈下降趋势,PaCO2则呈上升趋势,但均无统计学意义(P>0.05)。IAP15组、IAP25组与IAP0组比较,HR和CVP显著增加(P<0.05),CI和ITBVI则显著下降(P<0.05),但MAP无明显改变(P>0.05);ΔPes与CI的变化(ΔCI)呈负相关(r=-0.648,P<0.05)。结论急性肺损伤时,腹腔内压增高引起胸腔内压力增高,导致肺顺应性下降和心排出量下降。
文摘目的:评价通过跨肺压导向滴定呼气末正压(PEEP)个体化治疗急性呼吸窘迫综合征(ARDS)与其他调整PEEP的方法相比对患者是否获益更多。方法:计算机检索PubMed、Embase、Web of Science、Cochrane Library、中国知网、中国生物医学文献、维普、万方数据库中关于跨肺压导向PEEP滴定、其他方法调整PEEP治疗ARDS患者的相关随机对照研究,检索时间限定为建库以来至2021年8月15日,并对纳入文献进行meta分析。结果:共纳入16篇文献,累计样本量1075例,其中跨肺压导向PEEP滴定共540例,其他PEEP滴定方法共535例。meta分析结果显示:与其他方法调整PEEP相比,跨肺压导向PEEP滴定可改善ARDS患者的氧合指数(WMD=46.54,95%CI:27.63~65.46,P<0.05)、血氧饱和度(WMD=6.03,95%CI:4.67~7.39,P<0.05)、肺顺应性(WMD=6.97,95%CI:4.71~9.23,P<0.05)、28 d病死率(OR=0.55,95%CI:0.38~0.79,P=0.001)。结论:跨肺压导向PEEP滴定与其他滴定方法相比疗效、安全性更优。
