高频振荡与气管内气体吹入联合应用对重症急性呼吸窘迫综合征的急性影响。

Acute effects of combined high-frequency oscillation and tracheal gas insufflation in severe acute respiratory distress syndrome.

作者信息

Mentzelopoulos Spyros D, Roussos Charis, Koutsoukou Antonia, Sourlas Sotiris, Malachias Sotiris, Lachana Alexandra, Zakynthinos Spyros G

机构信息

First Department of Critical Care, University of Athens Medical School, Athens, Greece.

出版信息

Crit Care Med. 2007 Jun;35(6):1500-8. doi: 10.1097/01.CCM.0000265738.80832.BE.

DOI:10.1097/01.CCM.0000265738.80832.BE

PMID:17440419

Abstract

OBJECTIVE

In acute respiratory distress syndrome (ARDS), high-frequency oscillation (HFO) improves oxygenation relative to conventional mechanical ventilation (CMV). Alveolar ventilation is improved by adding tracheal gas insufflation (TGI) to CMV. We hypothesized that combined HFO and TGI (HFO-TGI) might result in improved gas exchange relative to both standard HFO and CMV according to the ARDS Network protocol.

DESIGN

Prospective, randomized, crossover study.

SETTING

A 30-bed university intensive care unit.

PATIENTS

A total of 14 patients with early (<72 hrs in duration), severe (PaO2/FiO2 of <150 mm Hg and prerecruitment oxygenation index of 22.8 +/- 1.9 [mean +/- SEM]), primary ARDS.

INTERVENTIONS

Patients were ventilated with HFO without (60 mins) and combined with TGI (6.1 +/- 0.1 L/min, 60 mins) in random order. HFO sessions were repeated in inverse order within 24 hrs. HFO sessions were preceded and followed by ARDS Network CMV. Four recruitment maneuvers were performed during the study period. During HFO sessions, mean airway pressure was set at 1 cm H2O above the point of maximal curvature of the respiratory system expiratory pressure-volume curve.

MEASUREMENTS AND MAIN RESULTS

Gas exchange and hemodynamics were determined before, during, and after HFO sessions. HFO-TGI improved PaO2/FiO2 relative to HFO and CMV (174.5 +/- 10.4 vs. 136.0 +/- 10.0 and 105.0 +/- 3.7 mm Hg, respectively, p < .05 for both) and oxygenation index relative to HFO (17.1 +/- 1.3 vs. 22.3 +/- 1.7, respectively p < .05). PaO2/FiO2 returned to baseline within 3 hrs after HFO. During HFO-TGI, shunt fraction and mixed venous oxygen saturation improved relative to CMV (0.36 +/- 0.01 vs. 0.45 +/- 0.01 and 77.8% +/- 1.2% vs. 71.8% +/- 1.3%, respectively, p < .05 for both). PaCO2 and hemodynamics were unaffected by HFO sessions. Respiratory mechanics remained unchanged throughout the study period.

CONCLUSIONS

In early onset, primary, severe ARDS, short-term HFO-TGI improves oxygenation relative to standard HFO and ARDS Network CMV.

摘要

目的

在急性呼吸窘迫综合征（ARDS）中，相对于传统机械通气（CMV），高频振荡通气（HFO）可改善氧合。通过在CMV基础上加用气管内气体吹入（TGI）可改善肺泡通气。我们假设，根据ARDS网络协议，联合应用HFO和TGI（HFO-TGI）可能比标准HFO和CMV都能带来更好的气体交换。

设计

前瞻性、随机、交叉研究。

地点

一家拥有30张床位的大学重症监护病房。

患者

共14例早期（病程<72小时）、重度（氧合指数<150 mmHg且招募前氧合指数为22.8±1.9 [均值±标准误]）的原发性ARDS患者。

干预措施

患者随机顺序接受单纯HFO通气（60分钟）以及联合TGI通气（6.1±0.1 L/分钟，60分钟）。HFO通气环节在24小时内以相反顺序重复进行。HFO通气环节前后均采用ARDS网络的CMV模式。研究期间进行4次肺复张操作。在HFO通气期间，平均气道压设定为高于呼吸系统呼气压力-容积曲线最大曲率点1 cm H2O。

测量指标及主要结果

在HFO通气环节前、中、后测定气体交换和血流动力学指标。相对于HFO和CMV，HFO-TGI可改善氧合指数（分别为174.5±10.4 vs. 136.0±10.0和105.0±3.7 mmHg，两者均p<0.05），相对于HFO可改善氧合指数（分别为17.1±1.3 vs. 22.3±1.7，p<0.05）。HFO后3小时内氧合指数恢复至基线水平。在HFO-TGI期间，相对于CMV，分流分数和混合静脉血氧饱和度有所改善（分别为0.36±0.01 vs. 0.45±0.01和77.8%±1.2% vs. 71.8%±1.3%，两者均p<0.05）。PaCO2和血流动力学指标不受HFO通气环节影响。整个研究期间呼吸力学保持不变。