Formenti Paolo, Umbrello Michele, Piva Ilaria R, Mistraletti Giovanni, Zaniboni Matteo, Spanu Paolo, Noto Andrea, Marini John J, Iapichino Gaetano
Unità Operativa di Anestesia e Rianimazione, Azienda Ospedaliera San Paolo-Polo Universitario, Milano, Italy.
Unità Operativa di Anestesia e Rianimazione, Azienda Ospedaliera San Paolo-Polo Universitario, Milano, Italy.
J Crit Care. 2014 Oct;29(5):808-13. doi: 10.1016/j.jcrc.2014.04.009. Epub 2014 Apr 26.
Pleural effusion (PE) is commonly encountered in mechanically ventilated, critically ill patients and is generally addressed with evacuation or by fluid displacement using increased airway pressure (P(AW)). However, except when massive or infected, clear evidence is lacking to guide its management. The aim of this study was to investigate the effect of recruitment maneuvers and drainage of unilateral PE on respiratory mechanics, gas exchange, and lung volume.
Fifteen critically ill and mechanically ventilated patients with unilateral PE were enrolled. A 3-step protocol (baseline, recruitment, and effusion drainage) was applied to patients with more than 400 mL of PE, as estimated by chest ultrasound. Predefined subgroup analysis compared patients with normal vs reduced chest wall compliance (C(CW)). Esophageal and P(AW)s, respiratory system, lung and C(CW)s, arterial blood gases, and end-expiratory lung volumes were recorded.
In the whole case mix, neither recruitment nor drainage improved gas exchange, lung volume, or tidal mechanics. When C(CW) was normal, recruitment improved lung compliance (81.9 [64.8-104.1] vs 103.7 [91.5-111.7] mL/cm H2O, P < .05), whereas drainage had no significant effect on total respiratory system mechanics or gas exchange, although it measurably increased lung volume (1717 vs 2150 mL, P < .05). In the setting of reduced C(CW), however, recruitment had no significant effect on total respiratory system mechanics or gas exchange, whereas pleural drainage improved respiratory system and C(CW)s as well as lung volume (42.7 [38.9-50.0] vs 47.0 [43.8-63.3], P < .05 and 97.4 [89.3-97.9] vs 126.7 [92.3-153.8] mL/cm H2O, P < .05 and 1580 vs 1750 mL, P < .05, respectively).
Drainage of a moderate-sized effusion should not be routinely performed in unselected population of critically ill patients. We suggest that measurement of C(CW) may help in the decision-making process.
胸腔积液（PE）在机械通气的重症患者中很常见，通常采用胸腔穿刺引流或通过增加气道压力（P(AW)）进行液体置换来处理。然而，除了大量胸腔积液或感染性胸腔积液外，缺乏明确的证据来指导其管理。本研究的目的是探讨肺复张手法和单侧胸腔积液引流对呼吸力学、气体交换和肺容积的影响。
纳入15例机械通气的重症单侧胸腔积液患者。根据胸部超声估计，对胸腔积液超过400 mL的患者应用三步方案（基线、肺复张和胸腔积液引流）。预定义的亚组分析比较了胸壁顺应性（C(CW)）正常与降低的患者。记录食管和P(AW)、呼吸系统、肺和C(CW)、动脉血气和呼气末肺容积。
在整个病例组合中，肺复张和胸腔积液引流均未改善气体交换、肺容积或潮气力学。当C(CW)正常时，肺复张可改善肺顺应性（81.9 [64.8 - 104.1] 对比 103.7 [91.5 - 111.7] mL/cm H2O，P < 0.05），而胸腔积液引流对总呼吸系统力学或气体交换无显著影响，尽管它可显著增加肺容积（1717对比2150 mL，P < 0.05）。然而，在C(CW)降低的情况下，肺复张对总呼吸系统力学或气体交换无显著影响，而胸腔积液引流可改善呼吸系统和C(CW)以及肺容积（42.7 [38.9 - 50.0] 对比 47.0 [43.8 - 63.3]，P < 0.05；97.4 [89.3 - 97.9] 对比 126.7 [92.3 - 153.8] mL/cm H2O，P < 0.05；1580对比1750 mL，P < 0.05）。
在未选择的重症患者群体中，不应常规进行中等量胸腔积液的引流。我们建议测量C(CW)可能有助于决策过程。
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