肺复张策略抢救急性呼吸窘迫综合征患者的最佳PEEP设置

摘要

目的 探讨肺复张(RM)策略抢救急性呼吸窘迫综合征(ARDS)患者的最佳PEEP设置.方法 将37例ARDS患者采用压力控制法肺复张后随机分为治疗组(n=19)和对照组(n=18),分别以P-V曲线呼气支拐点和吸气支低拐点+2cmH2O设置PEEP.比较2组患者RM前、后(15m in,1、2 h)氧合和呼吸系统动态顺应性、血流动力学等指标的变化.结果 2组RM后(15 min,1、2 h)的PaO2/FiO2较RM前均明显增高(P＜0.01),治疗组RM后(1、2 h)的PaO2/FiO2明显高于对照组(P＜0.05或P＜0.01);2组RM后的Cdyn短时间内(15m in)较RM前明显增高(P＜0.01),治疗组RM后(15 min,1、2h)均明显高于对照组(P＜0.05); RM后2组平均气道压、气道峰压均明显高于同组RM前(P＜0.01),2组组间比较无显著差异(P＞0.05);2组RM前后PaCO2比较无明显差异(P＞0.05);2组RM后短时间内(15m in)均有HR、CVP增高,MAP下降(P＜0.01).结论 肺复张策略能改善ARDS患者的氧合和呼吸系统顺应性,RM后以P-V曲线呼气支拐点设置PEEP更佳.%Objective To study the best PEEP settings of lung recruitment maneuver (RM) strategy in treatment of acute respiratory distress syndrome (ARDS) patients.Methods Thirtyseven ARDS patients after RM by using pressure control method were randomly divided into treatment group (n =19) and control group (n =18).For the treatment group,the inflection point on P-V curve deflation limb was taken as the best PEEP value.In the control group,the lower inflection point pressure (Plip) + 2 cmH2O in inflation limb on P-V curve was taken as the best PEEP value.The effects of PEEP on oxygenation and compliance of the respiratory system,hemodynamics indexes were monitored before RM and after RM (at 15 min,1 h and 2 h) in the two groups.Results PaO2 / FiO2 in the two groups of patients was significantly increased after RM (at 1 5 min,1 h,2 h)(P＜0.01),PaO2/FiO2 was higher in the treatment group after RM (at 1 h,2 h) than in the control group(P＜ 0.05,P ＜ 0.01).Cdyn in the two groups of patients was significantly increased shortly after RM (at 15 min)(P＜ 0.01).The Cdyn was higher in the treatment group after RM (at 15 min,1 h,2 h)than in the control group (P＜0.05).The mean airway pressure and peak airway pressure in the two groups were significantly increased after RM (P ＜ 0.01).The treatmentgroup and the control group were not significantly different after RM (P ＞ 0.0 5).The PaCO2 in the two groups were not significantly different after RM (P ＞0.05).In both groups,HR and CVP increased,and MAP decreased shortly after RM (at 15 min) (P＜0.01).Conclusion Lung RM strategy in treatment of ARDS patients improves oxygenation and compliance of the respiratory system.After RM,determining the PEEP for ARDS with the inflection point on P-V curve deflation limb is the best.