目的 探讨滴定最佳呼吸系统动态顺应性(Cdyn)设定呼气末正压(PEEP)对急性呼吸窘迫综合征(ARDS)婴幼儿预后的影响.方法 将广西壮族自治区妇幼保健院儿童重症监护病房(PICU)收治的30例ARDS婴幼儿按信封法随机分为对照组和治疗组,每组15例,分别使用美国ARDS协作网预先设定好的PEEP/吸入氧浓度(FiO2)对照表和滴定最佳Cdyn的方法设定PEEP,均采用压力控制通气(PCV)模式,小潮气量(7mL/kg)通气策略,监测2组患儿试验前及试验后呼吸力学、血流动力学、炎性因子等指标的变化,比较2组患儿机械通气时间、PICU住院时间及28 d病死率.结果 1.2组患儿性别、年龄、危重病例评分等一般情况比较差异无统计学意义(P均＞0.05).2.根据PEEP/FiO2对照表设定的PEEP值明显低于滴定最佳Cdyn方法确定的PEEP值[(6.4±1.4)cmH2O(1 cmH2O =0.098 kPa)比(9.9±1.6)cmH2O,P＜0.01].3.2组Cdyn、氧合指数(Ol)均有好转,治疗组好转程度较对照组明显[Cdyn试验后2 h:(0.39±0.03) mL/(cmH2O·kg)比(0.36±0.03) mL/(cmH2O·kg),P ＜0.05;24 h:(0.40 ±0.03) mL/(cmH2O·kg)比(0.38±0.03)mL/(cmH2O·kg),P＜0.05;48 h:(0.43±0.02) mL/(cmH2O·kg)比(0.40±0.02) mL/(cmH2O·kg),P＜0.01;OI试验后24 h:(20.07±2.12) cmH2O/mmHg(1 mmHg=0.133 kPa)比(21.94 ±2.05) cmH2O/mmHg,P＜ 0.05;48 h:(17.51±1.64) cmH2O/mmHg比(19.82±2.07) cmH2O/mmHg,P＜0.01];试验前后2组心率(HR)、平均动脉压(MAP)、心脏指数(CI)等比较差异均无统计学意义(P＞0.05).4.2组白细胞介素-6(IL-6)均呈进行性降低,治疗组降低程度较对照组更为明显[试验后24 h:(84.58±9.11) ng/L比(93.18 ±9.27)ng/L,P＜0.05;48 h:(76.67 ±9.23) ng/L比(90.10 ±9.42) ng/L,P＜0.01].5.治疗组机械通气时间、PICU住院时间均明显短于对照组[机械通气时间:(6.62±1.26)d比(8.06±1.44)d,P＜0.05;PICU住院时间:(8.12±1.31)d比(9.53±1.42)d,P＜0.05];2组患者均未有气压伤发生,病死率比较差异无统计学意义(P＞0.05).结论 滴定最佳Cdyn方法设定最佳PEEP能明显改善ARDS婴幼儿的呼吸力学,缩短机械通气时间,同时对血流动力学无严重不良影响.%Objective To investigate the impact of optimal respiratory system dynamic compliance (Cdyn) strategy for titrating positive end-expiratory pressure (PEEP)on the prognosis of acute respiratory distress syndrome (ARDS) in infants.Methods A total of 30 patients with ARDS admitted in Pediatric Intensive Care Unit (PICU) of Guangxi Maternity and Child Health Hospital were divided into 2 groups randomly (n =15).PEEP was set in the control group according to PEEP/FiO2 in American ARDS collaboration while optimal Cdyn was for the treatment group.Pressure control ventilation(PCV) mode and small tidal volume(7 mL/kg)strategy were taken.Respiratory mechanics,hemodynamics and inflammatory cytokines were monitored in each group before and after experiment.The time of assisted ventilation,and the hospital stay in PICU and 28-day mortality were compared.Results (1) There was no significant differences in gender,age and severity of disease between the 2 groups (all P ＞ 0.05).(2) The optimal PEEP of the control group was significant lower than that of the treatment group[(6.4 ± 1.4) cmH2O vs (9.9-± 1.6) cmH2O,P ＜ 0.01].(3) Cdyn and oxygenation index(OI) in 2 groups were all improved,and the degree of improvement in the treatment group was significantly better than that of the control group [Cdyn after the experiment at 2 h:(0.39 ± 0.03) mL/(cmH2O·kg) vs (0.36 ±0.03) mL/(cmH2O · kg),P＜0.05; 24 h:(0.40±0.03) mL/(cmH2O · kg) vs (0.38±0.03) mL/(cmH2O · kg),P ＜0.05; 48 h:(0.43 ±0.02) mL/(cmH2O · kg) vs (0.40 ± 0.02) mL/(cmH2 O · kg),P ＜ 0.01 ; OI after the experiment at 24 h:(20.07 ± 2.12) cmH2O/mmHg vs (21.94 ± 2.05),P ＜0.05 ; 48 h:(17.51 ± 1.64) cmH2O/mmHgvs (19.82 ± 2.07) cmH2O/mmHg,P ＜ 0.01] ; There were no significant differences in heart rate(HR),mean aerial pressure(MAP),cardiac index (CI) before and after the experiment (all P ＞ 0.05).(4) Interleukin-6 (IL-6) in two groups all decreased gradually,and the decrease in treatment group was more obvious than that of control group after the experiment at 24 h:(84.58-± 9.11) ng/L vs (93.18 ± 9.27) ng/L,P ＜ 0.05 ; 48 h:(76.67 ± 9.23) ng/L vs (90.10-± 9.42) ng/L,P ＜ 0.01.(5) The lengths of assisted ventilation and the hospital stay in PICU of the treatment group were significantly less than that of the control group [length of assisted ventilation:(6.62 ± 1.26) d vs (8.06-± 1.44) d ; the hospital stay in PICU:(8.12 ± 1.31) d vs (9.53 ±1.42) d,all P ＜0.05].There had no barotrauma and the mortality was not distinct between the two groups(P ＞ 0.05).Conclusions Optimal Cdyn method for titrating PEEP improves respiratory mechanics of ARDS obviously,shortens the time of assisted ventilation,and has no serious adverse effect on hemodynamics.
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