Department of Anesthesiology and Critical Care Medicine, Surgical Intensive Care Unit (EF), Department of Anesthesiology and Critical Care Medicine, Surgical Intensive Care Unit, Hôtel-Dieu Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France.
Crit Care Med. 2010 Apr;38(4):1108-17. doi: 10.1097/CCM.0b013e3181d451ec.
The impact of recruitment maneuvers on gas exchange, hemodynamics, alveolar recruitment, and hyperinflation is highly variable among patients with acute respiratory distress syndrome. The objective was to determine whether differences in lung morphology, defined as differences in the pulmonary distribution of aeration loss, predict the response to recruitment maneuvers.
Prospective study.
A 16-bed medical-surgical intensive care unit in a university hospital.
Nineteen consecutive patients with early acute lung injury/acute respiratory distress syndrome were studied. Computed tomography scans, respiratory mechanics, hemodynamics, and gas exchange were obtained at zero end-expiratory pressure during an open-lung ventilation (controlled mode, tidal volume 6 mL/kg of ideal body weight, positive end-expiratory pressure set 2 cm H2O above the lower inflection point of the inspiratory pressure volume curve at zero end-expiratory pressure) during a recruitment maneuver (continuous positive airway pressure of 40 cm H2O for 40 secs), and, finally, 5 mins after the recruitment maneuver during open-lung ventilation. Nine patients presented focal and 10 presented nonfocal lung morphology at zero end-expiratory pressure. Recruitment maneuver-induced recruited volume after 5 mins of open-lung ventilation was 48 +/- 66 mL and 417 +/- 293 mL in patients with focal and nonfocal lung morphology, respectively (p = .0009). Recruitment maneuver-induced alveolar hyperinflation represented 23% +/- 14% and 8% +/- 9% of total lung volume in patients with focal and nonfocal morphology, respectively (p = .007). In patients with focal lung morphology, hyperinflated lung volume was significantly greater during and 5 mins after (316 +/- 155 mL) than immediately before recruitment maneuvers (150 +/- 175 mL; p = .0407.
Lung morphology at zero end-expiratory pressure predicts the response to recruitment maneuvers. Patients with focal lung morphology are at risk for significant hyperinflation during the recruitment maneuvers, and lung recruitment is rather limited.
在急性呼吸窘迫综合征患者中，肺复张手法对气体交换、血流动力学、肺泡复张和过度充气的影响差异很大。本研究旨在确定肺形态学的差异（定义为通气损失的肺部分布差异）是否可以预测肺复张手法的反应。
前瞻性研究。
一所大学医院的 16 张病床的内科重症监护病房。
连续纳入 19 例早期急性肺损伤/急性呼吸窘迫综合征患者。在零呼气末正压通气下进行计算机断层扫描扫描、呼吸力学、血流动力学和气体交换，零呼气末正压通气时采用开放肺通气（控制模式，潮气量为理想体重的 6ml/kg，呼气末正压设置为零呼气末正压下压力容积曲线下拐点以上 2cmH2O），然后在肺复张手法（40cmH2O 持续气道正压 40 秒）后 5 分钟，并在开放肺通气期间进行。9 例患者在零呼气末正压时表现为局灶性肺形态，10 例患者表现为非局灶性肺形态。在开放肺通气 5 分钟后，肺复张手法引起的肺复张容积在局灶性和非局灶性肺形态患者中分别为 48 ± 66ml 和 417 ± 293ml（p =.0009）。肺复张手法引起的肺泡过度充气在局灶性和非局灶性形态患者中分别占总肺容量的 23% ± 14%和 8% ± 9%（p =.007）。在局灶性肺形态患者中，过度充气肺容积在肺复张手法期间和之后（316 ± 155ml）明显大于肺复张手法前（150 ± 175ml；p =.0407）。
零呼气末正压时的肺形态学可预测肺复张手法的反应。局灶性肺形态患者在肺复张手法期间有发生显著过度充气的风险，且肺复张的程度相当有限。
