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小潮气量通气加肺复张法对急性呼吸窘迫综合征疗效的影响.pdf
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    ·论著·

    小潮气量通气加肺复张法对急性呼吸窘迫综合征疗效的影响

    易丽 席修明

    【摘要】 目的 在小潮气量(V T )机械通气的基础上, 观察应用肺复张法(RM )治疗急性呼吸窘迫综合征

    (ARDS)的临床疗效, 为临床RM 的使用提供依据。方法 选择2003 年1 月—2004 年3 月北京复兴医院重症

    监护治疗病房( ICU )收治的 28 例ARDS 患者, 随机分为小V T + RM 组(RM 组)和小V T 组(non RM 组)。

    第一个 24 h 采用容量控制通气(CMV ) , 24 h 后根据病情选择机械通气方式。V T 6 m l? kg; 尽可能在吸入氧

    浓度(F iO 2) < 0160 时达目标氧合的最小呼气末正压(PEEP)水平, 限制平台压≤30 cm H2O (1 cm H2O =

    01098 kPa)。RM 为吸入纯氧, 持续气道正压(CPA P) 40 cm H2O , 持续40 s, 8 h 1 次, 共5 d。除RM 外, 其他

    治疗相同。记录基础状态和连续5 d 的机械通气参数、血气分析结果及生命体征, 比较两组氧合改善和肺损伤

    指标变化, 观察RM 的不良反应和气压伤发生率。结果 ①两组动脉血氧分压和氧合指数(PaO 2? F iO 2)均明

    显改善, 差异有显著性(P 均< 0105)。②两组白细胞介素 6 ( IL 6)水平均呈下降趋势, RM 组下降幅度更明

    显, 差异有显著性(P < 0105)。③两组均无气压伤发生。④RM 后心率无明显变化, 也无其他心律失常发生; 平

    均动脉压也无明显波动。结论 反复多次RM 可增加气体交换, 改善氧合, 进一步减少呼吸机相关性肺损伤

    (VAL I )。应用RM 较安全, 简便易行, 耐受性好, 临床观察未见低氧血症和对血流动力学的明显影响。

    【关键词】 急性呼吸窘迫综合征; 肺保护性通气; 肺复张

    Ef fects of recruitmen tmaneuvers with low t idal volume ven t ilat ion in pat ien ts with acute respiratory distress

    syndrome Y I L i

    3 , X I X iu m ing.

    3 Intensive Care U nit, Ch ina J ap an F riend sh ip H osp ital, B eij ing

    100029, Ch ina

    【Abstract】 Object ive To assess the effects of recruitment maneuvers (RM s) w ith low t idal vo lume

    (V T ) vent ilat ion on gas oxygenat ion and reduct ion of vent ilat ion associated lung injury (VAL I) in pat ients

    suffer ing f rom acute resp irato ry dist ress syndrome (ARDS) , to assess the effects of RM s on blood p ressure,hear t rate and occur rence of baro t rauma . Methods Pat ients in intensive care unit ( ICU ) of Beijing Fuxing

    Ho sp ital w ere random ized into two group s: low V T + RM group and low V T w ithout RM group (non RM

    group ). Tw enty eigh t pat ients w ith ear ly ARDS adm it ted f rom January 2003 to M arch 2004 w ere enro lled

    in the study . A ll pat ients received p ro tect ive vent ilat ion: V T w as set at 6m l? kg w ith p lateau p ressure lim ited

    at 30 cm H2O (1 cm H2O = 01098 kPa) o r low er, po sit ive end exp irato ry p ressure (PEEP) and f ract ion of

    insp ired oxygen (F iO 2 ) w ere set to obtain an par t ial p ressure of ar ter ial oxygen (PaO 2 ) betw een 60 to

    80 mm Hg (1mm Hg= 01133 kPa). RM sw ere conducted by regulat ing F iO 2 to 1100, app lying 40 cm H2O of

    cont inuous po sit ive airw ay p ressure (CPA P ) fo r 40 seconds, and then resumed the p revious vent ilato r

    set t ings (mode, PEEP, and F iO 2 ). Th is modality w as repeated once every 8 hours fo r a to tal of 5 days .

    M easurements of PaO 2? F iO 2, serum inter leuk in 6 ( IL 6) concent rat ion, resp irato ry and radiograph ic data,vent ilato ry parameters w ere obtained at baseline and fo r the f irst 5 days . M ean ar ter ial p ressure and hear t

    rate and pulse oxygen saturat ion (SpO 2) w ere measured befo re and af ter the RM. The p r imary outcome w as

    mo r tality at 28 days . Results ①A f ter RM , PaO 2? F iO 2 and PaO 2 in RM group and non RM group

    increased, but the values w ere h igher in RM group, and the difference betw een two group s w as signif icant

    (all P < 0105). ② IL 6 concent rat ions decreased in bo th group s but low er in RM group w ith signif icant

    difference (P < 0105). ③ Baro t rauma did no t occur r in bo th group s . ④No signif icant changes in blood

    p ressure and hear t rate w ere found dur ing RM s . HR andMA P remained unchanged af ter RM. Conclus ion

    RM could recruit the co llap sed alveo li in ARDS . It could signif icant ly imp rove oxygenat ion and decrease

    VAL I . A super impo sed RM is safe, and repeated RM could also decrease baro t rauma .

    【Key words】 acute resp irato ry dist ress syndrome; lung p ro tect ive vent ilat ion; lung

    recruitment maneuver

    基金项目: 北京市科技计划重大项目(H020920020530)

    作者单位: 100029 北京中日友好医院 ICU (易丽) ; 100038 首

    都医科大学附属复兴医院(席修明)

    作者简介: 易丽(1971 ) , 女(汉族) , 四川省人, 医学硕士, 主治

    医师(Email : ylp1cn@yahoo. com. cn) ......

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